Ultrasound-guided techniques for managing length- unstable femoral shaft fractures in children.

OBJECTIVE: The management of length-unstable femoral shaft fractures(LUFSFs) in pediatric patients is still controversial. This study aims to explore the clinical efficacy of ultrasound-guided closed reduction combined with external fixation for treating LUFSFs in children. METHODS: We conducted a retrospective analysis of clinical data from 19 pediatric patients with LUFSFs who underwent ultrasound-guided closed reduction and external fixation between January 2018 and January 2023. Ultrasound was employed not only to facilitate closed reduction of the fracture but also to guide real-time insertion of Schanz pins and monitor pin length as it traversed the opposite cortex. Surgical time, intraoperative fluoroscopy count, hospital stay length, fracture fixation duration, complication incidence, fracture reduction quality at the final follow-up were recorded. RESULTS: The patients' average age was 7.5 years( range: 5 to 11 years). The mean surgical duration was 70.4 min (range: 48-105 min), and the average intraoperative fluoroscopy count was 6.5 (range: 2-16). Fracture fixation lasted an average of 10.9 weeks (range: 7-20 weeks). All patients were followed up for more than one year. 6 cases of superficial pin tract infection occurred, which resolved with oral antibiotics and enhanced needle tract care. No deep infections were observed. Temporary stiffness of the knee joint was observed in 2 patients. According to Flynn's efficacy evaluation system, fracture reduction quality at the final follow-up was rated as excellent in 11 cases and satisfactory in 8 cases, yielding a combined success rate of 100% (19/19). CONCLUSIONS: The technique of ultrasound-guided closed reduction combined with external fixation offers favorable outcomes for children aged 5 to 11 years with LUFSFs, reducing reliance on fluoroscopic guidance.

Role of the ortho-bridge system in the length unstable subtrochanteric femur fracture in school going children: a retrospective clinical study of 19 cases.

Background: Treating subtrochanteric femur fractures in pediatric patients remains challenging, and an optimal fixation device has yet to be established. This study aimed to asess the clinical and radiological outcomes of Ortho-Bridge System (OBS) treatment for length-unstable subtrochanteric femur fractures in children aged 5-16 years. Methods: We conducted a retrospective review of pediatric patients with subtrochanteric femur fractures treated with OBS between January 2018 and December 2021. The study included 19 children (12 boys, 7 girls) with an average age of 10.4 ± 2.6 years. Two of the patients had pathological fractures associated with aneurysmal bone cyst. Demographic information, mechanism of accident, fracture type, associated neurovascular injuries, surgical duration and blood loss, were collected from the hospital database. Time to union and postoperative complications were recorded. Clinical and radiological outcomes were assessed using the Harris scoring system at the latest follow-up. Results: Injuries resulted from vehicle accidents in 10 patients (52.6%), falls over 3 meters in height in 3 patients (15.8%), and sports-related injuries in 6 patients (31.6%). The average patient weight was 41.5 kg (range: 21-78). Of the fractures, 14 (73.7%) were complex, and 5 (26.3%) were spiral. The average surgical duration was 111 min (range: 90-180), and the average surgical blood loss was 134 ml (range: 70-300). The mean time to union was 12.7 weeks (range: 8-16). No cases of infection, malunion, implant failure, or femoral head osteonecrosis were reported. Leg length discrepancy of 10 mm was observed in one patient. All patients achieved excellent results according to the Harris scoring system. Conclusion: This study suggests that the OBS may serve as an effective alternative fixation option for managing length-unstable subtrochanteric femur fractures in school-aged children.

Operative Choice for Length-Unstable Femoral Shaft Fracture in School-Aged Children: Locking Plate vs. Monolateral External Fixator.

BACKGROUND: Locking plate (LP) is a good choice in the treatment of length-unstable femoral shaft fracture in children. Monolateral external fixator (EF) has been reported for this condition for decades. This study aims to compare the clinical outcomes of school-aged children with length-unstable femoral shaft fracture treated with LP vs. EF. METHODS: Patients aged 5-11 years old with length-unstable femoral shaft fractures treated at our institute from January 2014 to January 2018 were retrospectively reviewed and categorized into LP and EF groups. The preoperative data, including baseline information of the patients, radiographic parameters, and types of surgical procedure, were collected from the hospital database, and postoperative data, including complications, were collected during the follow-up visits. RESULTS: Overall, 36 patients (average, 8.2 ± 2.1 years; male, 20; female, 16) in the LP group and 35 patients (average, 8.3 ± 2.3 years; male 20, female 15) in the EF group were included. There was significantly less operative time for EF (45.4 ± 7.8 min) compared with LP (67.8 ± 11.3 min) (P < 0.001). As for the frequency of fluoroscopy, there was a significant difference between the EF (13.9 ± 2.4) and LP (16.5 ± 3.2) groups (p < 0.001). The rate of major complications was not significantly different between these two groups. There was a significant difference between the EF group (11.2 ± 5.8 mm) and the LP group (7.5 ± 1.6 mm) group concerning limb length discrepancy (P < 0.001). CONCLUSION: Both LP and EF produce satisfactory outcomes in school-aged children with length unstable femoral shaft fractures. External fixation remains a viable choice without the necessity of secondary surgery for hardware removal.

Length unstable femoral fractures: A misnomer?

BACKGROUND: Flexible intramedullary nailing (FIMN) is relatively contraindicated for pediatric length unstable femoral fractures. AIM: To evaluate FIMN treatment outcomes for pediatric diaphyseal length unstable femoral fractures in patients aged 5 to 13 years. METHODS: This retrospective study includes pediatric patients (age range 5-13 years) who received operative treatment for a diaphyseal femoral fracture at a single institution between 2013 and 2019. Length unstable femur fractures treated with FIMN were compared to treatment with other fixation methods [locked intramedullary nailing (IMN), submuscular plating (SMP), and external fixation] and to length stable fractures treated with FIMN. Exclusion criteria included patients who had an underlying predisposition for fractures (e.g., pathologic fractures or osteogenesis imperfecta), polytrauma necessitating intensive care unit care and/or extensive management of other injuries, incomplete records, or no follow-up visits. Patients who had a length stable femoral fracture treated with modalities other than FIMN were excluded as well. RESULTS: Ninety-five fractures from ninety-two patients were included in the study and consists of three groups. These three groups are length unstable fractures treated with FIMN (n = 21), length stable fractures treated with FIMN (n = 45), and length unstable fractures treated with either locked IMN, SMP, or external fixator (n = 29). P values < 0.05 were considered statistically significant. Patient characteristic differences that were statistically significant between the groups, length unstable with FIMN and length unstable with locked IMN, SMP, or external fixator, were average age (7.4 years vs 9.3 years, respectively), estimated blood loss (29.2 mL vs 98 mL, respectively) and body mass (27.8 kg vs 35.1 kg, respectively). All other patient characteristic differences were statistically insignificant. Regarding complications, length unstable with FIMN had 9 total complications while length unstable with locked IMN, SMP, or external fixator had 10. Grouping these complications into minor or major, length unstable with locked IMN, SMP, or external fixator had 6 major complication while length unstable with FIMN had 0 major complications. This difference in major complications was statistically significant. Lastly, when comparing patient characteristics between the groups, length unstable with FIMN and length stable with FIMN, all characteristics were statistically similar except time to weight bearing (39 d vs 29 d respectively). When analyzing complication differences between these two groups (9 total complications, 0 major vs 20 total complications, 4 major), the complication rates were considered statistically similar. CONCLUSION: FIMN is effective for length unstable fractures, having a low rate of complications. FIMN is a suitable option for length stable and length unstable femur fractures alike.

Unstable Pediatric Femur Fractures: Combined Intramedullary Flexible Nails and External Fixation.

INTRODUCTION: The treatment of pediatric femur fractures continues to evolve. In the past, many of these fractures required prolonged hospitalization in traction. More recently, flexible elastic nails have gained popularity. However, length unstable and comminuted fractures can present some unique challenges. To avoid common complications of elastic nailing in the setting of unstable fractures we describe a technique of augmenting this treatment with external fixation for cases requiring additional rotational or longitudinal stability. CASE REPORT: A series of two patients are described who underwent intramedullary flexible nails and external fixation for a closed unstable midshaft femur fracture: An 8-year-old male that sustained a left periprosthetic femur fracture after a fall on his scooter, and a 5-year-old female that sustained a right femur fracture after a fall from a wet decking. Both patients had their external fixator removed after 4 weeks and achieved radiographic and clinical fracture union at 8-week postoperatively. CONCLUSION: Treatment with elastic nails and external fixator for unstable pediatric femur fractures is a minimally invasive technique that safely provides fracture stability.