Abstract: Femoral fractures are common long bone fractures in school-aged children. Among the various treatment options, flexible intramedullary nailing is becoming increasingly popular, although the supporting evidence for it is still relatively scarce. This study examined the efficacy of flexible intramedullary nailing for school-aged children and its complications through a systematic review of the relevant literature. Although most complications were mild, some series reported complication rates in excess of 50%. Bone discontinuity and shaft misalignment are common, and unequal thigh lengths are not uncommon.
Graft reactions are also common, especially when the end of the nail is long and protruding. The incidence of re-fracture is less common in this group. Flexible intramedullary nailing is a widely accepted and reliable treatment modality for femur fractures in school-aged children. It allows for a reduced hospital stay, early return to function and a high healing rate. Treatment must allow the patient to obtain and maintain repositioning of the fracture, with attention to older children and heavier children.
Full Text: Femoral fractures are a common type of long bone fracture in school-aged children. These injuries are a burden to health care providers, as well as to society, as their recovery requires that the patient and accompanying caregivers be unable to work. A variety of treatments are available, including external fixation, traction, internal fixation, locking nails, and intramedullary nailing. All of these treatments have been successful in treating these fractures, but there are differences in stability and potential complications. The primary goals of treatment include preservation of growth capacity, anatomic repositioning, and firm fixation. Some forms of fixation require adjunctive plaster fixation for a period of time to gain additional stability. children 6-12 years of age are heavier than children under 6 years of age and cannot tolerate plaster fixation, thus making the choice of treatment more confusing.
Each form of fixation has its complications. For example, external fixation is prone to pinhole infection and re-fracture, while traction can cause limb lengthening and instability. Internal fixation can cause extensive incision and soft tissue stripping injuries, locking nails can cause spontaneous combustion-appearing injuries, and these associated complications are by no means the only ones, and there are many more.
According to the American Academy of Orthopaedic Surgeons guidelines for the treatment of pediatric femoral fractures, the flexible intramedullary nail is a reliable treatment option for these patients. The flexible intramedullary nail has its own set of problems, including nail irritation, re-fracture, and surface and deep infection. In addition some investigations have shown a significant risk of treatment failure in older and heavier children.
This article raises the following questions.
1. the reported outcomes of elastic intramedullary nail fixation in school-aged children.
2. the complications and incidence of the application of flexible intramedullary nailing in school-aged children.
3. the quality of the selected articles. We systematically review the articles to answer these questions and report relevant data to assist patients and their families in deciding on treatment modalities.
Methods.
We searched the MEDLINE and EMBASE databases for articles published from January 1980-June 2008 with titles including the following entries: femoral fracture or femoral fracture in children aged 6-12 years, English, human. All searched articles were included in the evaluation.
The following criteria were met for inclusion in this article review.
1, English.
2, Level I,II,III,IV studies rated by the Journal of Bone and Joint Surgery criteria.
3, Minimum 15 cases.
4, All study subjects were between 6 and 12 years old.
5.A minimum of 6 months postoperative observation or knowledge of fracture healing.
6, Patients treated by applying other methods are listed separately.
Exclusion criteria.
1, The study contained open fractures not easily separated from closed fractures.
2, The study applied inappropriate follow-up.
3. The study does not easily exclude those too large or too small children and those applying different forms of treatment.
4. Combined fractures of other sites.
Two authors screened articles and three authors selected articles for further study based on the above criteria. We obtained 156 articles from PUBMED and 239 articles from EMBASE. The total number of articles was 353 and 21 articles were duplicated. Among them, 232 articles were excluded. The abstracts of the remaining 121 articles were read, and 105 articles were excluded because of irrelevant content. Of the remaining 16 studies, 8 did not match the surgical criteria and 8 met the criteria. The references of the readily included articles were also carefully searched to identify 17 potentially relevant articles, and nine of them were excluded by applying the criteria. A final total of 16 studies were included in this article, for a total of 1128 pediatric patients with femoral fractures.
Patients with combined other fractures requiring fixation were excluded from this article. Infections included those requiring surgical treatment or pharmacological treatment. Healing time was calculated for each individual using the mean or median. Re-fracture was defined as any trauma-induced fracture reoccurring after fracture healing, with or without removal of internal fixation. The criteria for excellent, good, and poor were judged by the criteria in the article by Flynn et al.
Results.
The results of our data showed 99.5% fracture healing rate and 0.05 non-healing rate. Healing time was 4 weeks-11 weeks. Internal fixation was removed at routine times. Some patients required early removal of the internal fixation, and more than 80% of the nails shifted. The incidence of axial malalignment was about 1/3. 63.6% of patients had satisfactory results according to Flynn et al. 26.2% had good results. 10.2% had poor results. The average length of stay was 4-11 days. The average cost was $2,500-$3,000. This is less than the cost of post-traction cast fixation. However, post-traction cast fixation requires fewer films and fewer reviews.
22 cases of infection were caused by surgical procedures. From superficial to deep infections requiring debridement. Symptomatic reaction to internal fixation was 23.44%. One article reached 60%. 9 cases presented with re-fracture. The incidence of axial malalignment ranged from 0 in one article to 1/3 in one article. the overall incidence was 15.1%.
Two articles met our criteria for accurate analysis. Both compared the effect of flexible intramedullary nailing with post-traction cast fixation. Both articles concluded that the total direct and indirect costs of post-traction cast fixation were higher. Complications were 34.3% higher in the post-traction cast fixation than in the elastic intramedullary nailing group with 18.9%. The incidence of bone nonunion was 10% in the elastic intramedullary nailing group and 18% in the post-traction cast fixation group. One of the studies analyzed function and found that the flexible intramedullary nail group walked with crutches, walked independently, and returned to school earlier than the plaster fixation group. Another study analyzed satisfaction and found that 96% of patients in the flexible intramedullary nailing group said they would choose flexible intramedullary nailing again, compared to 6% in the traction group.
All study groups met the criteria, with three achieving grade IV, two achieving grade III, and one achieving grade II. Only 2 studies had a control group. Almost all studies were reported as current. Two studies had early expected inclusion criteria. three studies applied binary choice regression to control for confounding. Two studies applied gold standard controls and in addition four studies applied standard outcome measures.