Treatment of closed femoral shaft fractures in children aged 2–10 years: a systematic review and meta-analysis

Abstract

Objective To review current literature on treatment of closed femoral shaft fractures in children of 2–10 years old, with subgroup analysis of children aged 2–6 years, comparing intramedullary nailing (IMN) to conservative treatment modalities. Methods We included clinical trials and observational studies that compared traction and subsequent casting (TSC), spica casting and IMN for treatment of femur shaft fractures in children of 2–10 years of age. Subgroup analysis of children aged 2–6 years was performed. Results Compared to treatment with immediate spica casting, IMN led to significantly less coronal angulation (mean difference (MD): 2.03 degrees, confidence interval (CI) 1.15–2.90), less sagittal angulation (MD: 1.59 degrees, CI 0.82–2.35) and lower rates of LLD (Risk difference (RD): 0.07, CI 0.03–0.11). In terms of rehabilitation, IMN leaded to shorter time until walking with aids (MD: 31.53 days, CI 16.02–47.03), shorter time until independent ambulation (MD: 26.59 days, CI 22.07, 31.11) and shorter time until full weight bearing (MD: 27.05 days, CI 6.11, 47,99). Compared to TSC, IMN led to a lower rate of malunion (RD: 0.31, CI 0.05–0.56), shorter hospital stays (MD: 12.48 days, CI 11.57, 13.39), time until walking with aids (MD: 54.55, CI 40.05–69.04) and full weight bearing (MD: 27.05 days [6.11, 47,99]). Conclusion Although a lack of quality evidence, this systematic review showed a clear tendency to treatment with elastic intramedullary nails of femoral shaft fractures in children of 2–10 years of age. Level of evidence 3.

ESIN in femur fractures in children under 3: is it safe?

“…Gordon et al reported no significant difference in fracture healing between ESIN and non-operative treatment in femur fractures, however outlines the higher impact on the family in the non-operative group due to higher need of care [ 1 ]. Van Cruchten et al suggested in their systematic review, that overall satisfaction of the parents and the patients after treatment was higher in the ESIN group [ 32 ]. Hughes et al identified impaired mobility due to spica casting of femur fracture as the main factor of family impact.…”

Therapy preference of 131 parents confronted with a pediatric femoral fracture

“…A recently published meta-analysis of treatment of closed femoral shaft fractures in children aged 2–10 years including 21 studies with 1,675 patients found significantly lower rates of malunion, lower means of angulation and shortening and earlier achievement of rehabilitation in children treated with ESIN compared with both immediate spica casting and traction and subsequent casting ( 11 ). Moreover, also a subgroup analysis of children aged between 2 and 6 years showed superior radiological outcomes and faster reconvalescence in the ESIN group ( 11 ). Shorter hospital stay, early mobilization and weight bearing were mentioned as additional benefits of ESIN in the literature ( 16 , 23 , 24 ).…”

“…Immediate application of SC is often not possible without general anesthesia due to initial malalignment and in addition, the soft tissue to bone relation and muscular traction may still promote secondary displacement. Moreover, leg length discrepancy, malunion and skin breakdown are known complications ( 10 , 11 ).…”

“…Recently, however, surgical treatment using elastic stable intramedullary nailing (ESIN) has gained increased acceptance for fracture treatment even in toddlers ( 11 ). Especially in large trauma centers, femoral fractures in early childhood are increasingly treated surgically ( 4 , 5 ).…”

“…Only a few studies have directly compared conservative and surgical management of pediatric femoral fractures in preschool-aged children ( 12 – 15 ). Authors using ESIN in children younger than 5 years of age mention better fracture reduction, a quicker discharge (the mean inpatient duration is 6.4 days), and a faster weight-bearing after an average of 14.1 days without an increase of morbidity as major advantages of this approach ( 11 , 13 , 14 , 16 , 17 ). However, ESIN requires a second operation in general anesthesia after approximately 6 months for implant removal and is associated with potential but rare complications such as displacement with shortening or varus deviation (reported in 3.3% of the cases) and minor restrictions without the need for revision such as hematomas, hypertrophic scarring, and temporary functional impairments in up to 25% of patients treated with ESIN ( 18 ).…”