“Unstable” Pediatric Femoral Shaft Fractures Treated With Flexible Elastic Nails Have Few Complications

Abstract

Objectives: To determine our complication rate in pediatric femoral shaft fractures treated with flexible elastic nailing and to determine fracture characteristics that may predict complications. Design: Retrospective cohort study. Setting: One Level 1 and One Level 2 academic trauma centers. Patients/Participants: One hundred one pediatric femoral shaft fractures treated from 2006 to 2018. Main Outcome Measurement: Major and minor complications. Results: One hundred one femurs met inclusion criteria. The average age was 7 years (range 3–12 years). The average weight was 29.0 kg (range 16–55 kg). The average follow-up was 11 months (6–36 months). Ninety-three patients underwent elective implant removal at our institution. Fifty-one of the 101 (50%) fractures were “unstable” patterns. Ninety-three percent had implants that filled >80% of the canal (69 titanium and 32 stainless steel). Seventeen percent (18) had cast immobilization. All fractures went on to union. No patient required revision surgery for malunion as follows: 6 had coronal/sagittal malalignment >10 degrees, 3 had malrotation >15 degrees, and none had a leg length inequality >1 cm. Three patients had an unplanned surgery as follows: 2 for prominent implants and 1 for refracture after a second injury. There were no patient, fracture, or treatment characteristics that were predictive of complications or unplanned surgery, including “unstable” fractures (P = 0.78). Conclusion: Our study demonstrates that flexible elastic nailing can be safely used in most pediatric femoral shaft fractures, including those previously described as “unstable.” Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Adult Proximal Humeral Locking Plate Is a Good Alternative Option in the Treatment of Adolescent Subtrochanteric Femur Fractures: A Case Series and Literature Review

“…Many types of implants, including TENs, antegrade IMN, condylar blade plates, and reconstruction plates, are used for the fixation of pediatric SFFs. Studies have demonstrated the safety and effectiveness of TEN for treatment of displaced fractures of the femoral shaft in children aged 6-12 years and weighing less than 50 kg (110 lb); however, its use is controversial in children older than those in this age range and weight, and in SFFs 28 29 30) . In addition, due to loss of reduction in adolescents, it can lead to development of LLD, malalignment, and sagittal plane angulation 31) .…”

Length Unstable Pediatric Tibial Shaft Fracture Treated With Cerclage Augmented Elastic Intramedullary Nails: A Novel Technique

“…However, unstable pediatric femoral shaft fractures (both failed conservative and inherent length unstable patterns) have been shown to be amenable to EIN 11. This is true even for children above the weight limit recommended by the American Academy of Orthopaedic Surgeons guidelines 15,18. In theory, EIN may be successful in unstable femur fractures due to the femur being fully encased in strong muscular compartments.…”

“…11 This is true even for children above the weight limit recommended by the American Academy of Orthopaedic Surgeons guidelines. 15,18 In theory, EIN may be successful in unstable femur fractures due to the femur being fully encased in strong muscular compartments. This type of splinting can be likened to the function of a sarmiento brace for humerus fractures.…”

Treatment of Pediatric Femoral Shaft Fractures

“…30,31 In summary, proper patient selection and surgical management of implants during flexible intramedullary nail placement (eg, choice of metal, canal fill, and implant management at entry sites) is important. Atassi et al 32 recently reported low complication rates in a series of 101 fractures treated with flexible intramedullary nails (of which they defined 50% as "unstable"). Unfortunately, a power analysis revealed that a sample size of 1,262 patients would be necessary to detect a statistically significant difference in major complications between stable and unstable fracture patterns.…”