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

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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

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Most cited references 54

Record: found
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Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications.

J. Flynn, M T Hresko, R A Reynolds … (2015)

Titanium elastic nailing is used instead of traction and casting in many European centers, but limited availability has prevented widespread use in North America. Before a planned general release in America, titanium elastic nails (TENs) were trialed at several major pediatric trauma centers. This multicenter study is a critical analysis of early results and complications of the initial experience. Overall, TENs allowed rapid mobilization with few complications. The results were excellent or satisfactory in 57 of the 58 cases. No child lost rotational alignment in the postoperative period. Irritation of the soft tissue near the knee by the nail tip occurred in four patients, leading to a deeper infection in two cases. As indications, implantation technique, and aftercare are refined, TENs may prove to be the ideal implant to stabilize many pediatric femur fractures, avoiding the prolonged immobilization and complications of traction and spica casting.

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Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children.

J Dawson, Kathleen Ganley, J Dormans … (2004)

Titanium elastic nails are commonly used to stabilize femoral fractures in school-aged children, but there have been few studies assessing the risks and benefits of this procedure compared with those of traditional traction and application of a spica cast. This prospective cohort study was designed to evaluate these two methods of treatment, with a specific focus on the first year after injury, the period when the treatment method should have the greatest impact. Eighty-three consecutive children, six to sixteen years of age, were studied prospectively. Factors that were analyzed included clinical and radiographic data, complications, hospital charges, and outcome data. Outcome and recovery were assessed both with the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collections Instrument, version 2.0, and according to a series of important recovery milestones including the time to walking with aids, time to independent walking, time absent from school, and time until full activity was allowed. Thirty-five children (thirty-five fractures), with a mean age of 8.7 years, were treated with traction and application of a spica cast, and forty-eight children (forty-nine fractures), with a mean age of 10.2 years, were treated with titanium elastic nails. All fractures healed, and no child sustained a complication that was expected to cause permanent disability. At one year after the fracture, eighty of the children had acceptable alignment and no inequality between the lengths of the lower extremities. The remaining three children, who had an unsatisfactory result, had been treated with traction and a spica cast. Twelve patients (34%) treated with traction and a cast had a complication compared with ten patients (21%) treated with titanium elastic nails. Compared with the children treated with traction and a cast, those treated with titanium elastic nails had shorter hospitalization, walked with support sooner, walked independently sooner, and returned to school earlier. These differences were significant (p < 0.0001). We could detect no difference in total hospital charges between the two groups. The results of this prospective study support the recent empiric observations and published results of retrospective series indicating that a child in whom a femoral fracture is treated with titanium elastic nails achieves recovery milestones significantly faster than a child treated with traction and a spica cast. Hospital charges for the two treatment methods are similar. The complication rate associated with nailing compares favorably with that associated with traction and application of a spica cast.

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Management of pediatric femoral shaft fractures.

John M Flynn, Richard Schwend (2015)

Femoral shaft fractures are the most common major pediatric injuries managed by the orthopaedic surgeon. Management is influenced by associated injuries or multiple trauma, fracture personality, age, family issues, and cost. In addition, child abuse should be considered in a young child with a femoral fracture. Nonsurgical management, usually with early spica cast application, is preferred in younger children. Surgery is common for the school-age child and for patients with high-energy trauma. In the older child, traction followed by casting, external fixation, flexible intramedullary nails, and plate fixation have specific indications. The skeletally mature teenager is treated with rigid intramedullary fixation. Potential complications of treatment include shortening, angular and rotational deformity, delayed union, nonunion, compartment syndrome, overgrowth, infection, skin problems, and scarring. Risks of surgical management include refracture after external fixator or plate removal, osteonecrosis after rigid antegrade intramedullary nail fixation, and soft-tissue irritation caused by the ends of flexible nails.

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Author and article information

Contributors

Stijn van Cruchten:

ORCID: http://orcid.org/0000-0001-5477-0228

stijnvancruchten@gmail.com

Journal

Journal ID (nlm-ta): Eur J Trauma Emerg Surg

Journal ID (iso-abbrev): Eur J Trauma Emerg Surg

Title: European Journal of Trauma and Emergency Surgery

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 1863-9933

ISSN (Electronic): 1863-9941

Publication date (Electronic): 2 August 2021

Publication date PMC-release: 2 August 2021

Publication date (Print): 2022

Volume: 48

Issue: 5

Pages: 3409-3427

Affiliations

[1 ]GRID grid.7692.a, ISNI 0000000090126352, UMC Utrecht, ; Heidelberglaan 100, 3584 CX Utrecht, The Netherlands

[2 ]Reinier Haga Orthopedisch Centrum, Toneellaan 2, 2725 NA Zoetermeer, The Netherlands

[3 ]GRID grid.416135.4, ISNI 0000 0004 0649 0805, Erasmus MC/Sophia Children’s Hospital, ; Wytemaweg 80, 3015 CN Rotterdam, The Netherlands

[4 ]Kromme Nieuwegracht 15, 3512 HC Utrecht, The Netherlands

Author information

Stijn van Cruchten http://orcid.org/0000-0001-5477-0228

Article

Publisher ID: 1752

DOI: 10.1007/s00068-021-01752-7

PMC ID: 9532337

PubMed ID: 34338819

SO-VID: 3f2b4b6a-63ca-476a-8d52-e01fcd0e0400

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 14 March 2021

Date accepted : 18 July 2021

Custom metadata

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: femur shaft fractures,pediatric,intramedullary nails,spica cast,traction,titanium elastic nails

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ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: femur shaft fractures, pediatric, intramedullary nails, spica cast, traction, titanium elastic nails

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

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Abstract

Objective

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Level of evidence

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Irish Journal of Paramedicine

Most cited references 54

Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications.

Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children.

Management of pediatric femoral shaft fractures.

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