Defining Length Stability in Paediatric Femoral Shaft Fractures Treated with Titanium Elastic Nails

Abstract

Introduction Optimal paediatric femoral shaft fracture patterns or lengths amenable to titanium elastic nail stabilization have not been well defined. The purpose of this study is to identify radiographic parameters predictive of treatment failure with flexible intramedullary nails based upon fracture morphology. Methods A retrospective review was performed of all femoral shaft fractures treated with flexible intramedullary nails over a five-year period. All patients with at least six weeks of postoperative radiographic imaging were included. Fracture characteristics included location, pattern, length, obliquity, angulation, translation and shortening. Postoperative radiographs were reviewed to determine shortening and angulation. Results There were 58 patients with 60 femoral shaft fractures stabilized with titanium nails, with 46 healing within acceptable parameters and 14 considered malunions. Six of the 14 malunions developed complications requiring early unplanned intervention. No patients in the treatment success group had a complication. Between the treatment success and failure groups, fracture pattern, location, length, obliquity, angulation, translation or shortening were not statistically different. Mean nail canal fill was significantly lower in the failure group (0.72 versus 0.81; p = 0.0146), with a receiver operating characteristic curve identifying canal fill 76% as the optimal threshold. Conclusion This is the first study to measure the length and obliquity of paediatric femoral shaft fractures and to determine their relationship to radiographic alignment after healing. None of the preoperative fracture characteristics were predictive of malalignment or shortening. We recommend the use of larger nail sizes in the treatment of paediatric femoral shaft fractures, especially if there is concern for residual instability. Level of evidence IV

Elastic Stable Intramedullary Nailing in Length Stable Versus Unstable Pediatric Femoral Shaft Fractures: A Comparison of Clinical, Radiographic, and Pedobarographic Outcomes

“…On the other hand, more recent studies reported no significant difference in complication rates between length stable and unstable PDFF. [10][11][12] Over the last 2 decades, our indications for the use of ESIN in PDFF have also expanded from the simple transverse or short oblique fractures toward more unstable fracture patterns in line with the literature. The majority of PDFF have been treated with ESIN in our institution, regardless of the stability of the fracture pattern.…”

Closed reduction and titanium elastic nailing in diaphyseal femoral and tibial fractures in children

“…Andreacchio et al reported that higher weight (> 50 kg) as a potential risk factor associated with poor clinical outcomes 29 . Shieh et al defined that unstable fracture pattern as fracture length greater than twice the cortical width 30 . In the present study, we could not reach the weight information of the patients at the time of surgery.…”

Length Unstable Femoral Shaft Fractures in Children: It's Time for a New Definition

“…The current study by Nixon and his St Louis coauthors 8 in this issue of J Orthop Trauma adds to the growing body of literature (at least the seventh study) that supports the use of ESIN in unstable femoral shaft fractures. 9–14 Using the same definition of unstable as Sink et al did in 2005, Nixon et al compared 63 stable and 43 unstable femoral shaft fracture patients and found no difference in major complication rates (12.7% and 11.6%, respectively). Nail tip irritation was not defined as a major complication—which is reasonable because the nails are usually not intended for permanent implantation.…”