Background: Controversy exists regarding the treatment of length unstable pediatric femoral shaft fractures. The purpose of this study was to investigate the outcomes of skeletally immature children with length unstable femur fractures treated with titanium elastic nails (TENs). Methods: A retrospective review was conducted on all patients with femoral shaft fractures at a tertiary care pediatric hospital from April 2006 to January 2018. Patients with femoral shaft fractures treated with TEN and minimum 6 months follow-up were included. Exclusion criteria were age 11 years or above, weight >50 kg, pathologic fracture, and neuromuscular disorders. Femur fractures were categorized into 2 groups: length unstable (spiral, comminuted, or long oblique fractures) versus length stable (transverse and short oblique). Complications and reoperations were compared between the groups. Results: A total of 57 patients with 58 femoral shaft fractures were included. The mean age was 5±2 (1 to 11) years and mean follow-up was 20.4±18.1 (6.0 to 81.2) months. The mean weight was 22.9±7.7 (11.0 to 40.5) kg. There was no difference in age (P=0.32), weight (P=0.28) or follow-up length (P=0.57) between patients with length unstable fractures and those with length stable fractures. A total of 32/58 (55%) fractures were length unstable and 26/58 (45%) were length stable. Mean time to union was 4.6 months, and there was no significant difference in mean time to union between the 2 groups (P=0.71). Thirty-one complications occurred in 27 patients. There was no difference between groups in the incidence of major complications requiring revision surgery (P=0.68) and minor complications that did not require revision surgery (P>0.99). Conclusions: In children with femoral shaft fractures treated with TEN, there was no difference in the incidence of complications or reoperations between those with length unstable fractures and those with length stable fractures. TEN are a safe and effective choice for operative fixation of length unstable femoral shaft fractures in children. Level of Evidence: Level III—retrospective comparative study.

Therapeutic Level IV.

As a group, the extremities are the most commonly injured anatomic region in nonfatal firearm trauma and are associated with high rates of vascular and bony injury. This study examines the epidemiology, incidence and distribution of firearm-related extremity trauma and the relationship between injury pattern and local or systemic complications. Review of the National Trauma Databank identified 6987 patients with isolated extremity firearm injury. Epidemiologic data, injury pattern incidence, and local and systemic complications were reviewed. Multivariate analysis identified the impact of extremity injury pattern on complications. Overall fracture incidence was 22 per cent. Fracture was associated with both vascular (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.5 to 2.4; P < 0.001) and nerve injury (OR, 2.6; 95% CI, 1.9 to 3.5; P < 0.001). Isolated fracture increased risk of compartment syndrome (OR, 2.4; 95% CI, 1.1 to 5.3; P = 0.035). Vascular injury alone increased the risk of compartment syndrome (OR, 11.5; 95% CI, 5.0 to 26.2; P < 0.001) and deep venous thrombosis (OR, 7.9; 95% CI, 2.5 to 25.2; P < 0.001). Fracture and vascular injury together also increased risk of wound infection (OR, 9.7; 95% CI, 3.9 to 23.4; P < 0.001). In patients with extremity trauma, the injury pattern significantly impacts local but not systemic complication rates. Gunshot-related fracture, occurring in one-fifth of patients, increases the risk of vascular and nerve injury. Vascular injury, with or without fracture, is the biggest predictor of local complications.