Pediatric Diaphyseal Femur Fractures: Submuscular Plating Compared With Intramedullary Nailing

Abstract

This study compared the radiographic and clinical outcomes of pediatric diaphyseal femur fractures treated by submuscular plating, flexible retrograde intramedullary nailing, or rigid antegrade intramedullary nailing with a trochanteric entry point in skeletally immature patients who were 8 years and older. A retrospective review was conducted of skeletally immature patients 8 years and older who were treated for femur fracture with submuscular plating, flexible intramedullary nailing, or rigid intramedullary nailing from 2001 to 2014 with a minimum 12-week follow-up. Treatment outcomes were compared for statistical significance, including time to union, malunion, nonunion, heterotopic ossification, avascular necrosis, time to full weight bearing, limb length discrepancy, residual limp, painful hardware, and infection. The study identified 198 femur fractures in 196 patients (mean age, 11.9 years). Each femur fracture was treated with submuscular plating (35), flexible intramedullary nailing (61), or rigid intramedullary nailing (102). Mean follow-up across the cohort was 48 weeks, ranging from 12 to 225 weeks. Flexible nailing was associated with an increased incidence of malunion (P<.0001) and hardware irritation (P=.0204) and longer time to full weight bearing (P=.0018). Rigid nailing was associated with an increased incidence of limp at 12-week followup (P=.0412). Additionally, 23.5% of patients who were treated with rigid nailing had heterotopic ossification. Of all surgical methods, submuscular plating allowed for the most rapid return to full weight bearing (mean, 7 weeks) and offered the fastest healing rate (mean, 6 weeks). Submuscular plating resulted in faster times to union and full weight bearing, with minimal complication rates. Rigid intramedullary nailing with trochanteric entry resulted in a lower incidence of malunion and hardware-related complications; however, these patients had an increased incidence of heterotopic ossification and residual limp postoperatively. Flexible retrograde intramedullary nailing resulted in the highest rates of malunion and hardware irritation and the longest time to full weight bearing. [Orthopedics. 2016; 39(6):353-358.].

Submuscular plates versus flexible nails in preadolescent diaphyseal femur fractures

“… 20 A study published in 2016 compared postoperative outcomes in 198 skeletally immature patients eight years or older who underwent treatment with SMPs, FNs or rigid intramedullary nailing, and did not examine surgical parameters such as EBL or operative time. 21 Our study results are consistent with those of the 2012 study in terms of operative time and EBL 20 and with the 2016 study in terms of a higher incidence of irritation among patients treated with FNs (23% of 61 patients treated with FNs versus 2.9% of 35 patients treated with SMPs, p not reported). 21 Soft-tissue irritation has been reported as a complication of FNs in multiple studies, with incidence ranging from < 10% to as high as 52% 22 but is minor in most cases and relieved with implant removal.…”

“… 21 Our study results are consistent with those of the 2012 study in terms of operative time and EBL 20 and with the 2016 study in terms of a higher incidence of irritation among patients treated with FNs (23% of 61 patients treated with FNs versus 2.9% of 35 patients treated with SMPs, p not reported). 21 Soft-tissue irritation has been reported as a complication of FNs in multiple studies, with incidence ranging from < 10% to as high as 52% 22 but is minor in most cases and relieved with implant removal. 8 , 21 , 23 – 25 Proposed risk factors for irritation include bent or prominent nail ends, 22 earlier mobilization of the knee 12 and excessive nail protrusion at the time of implantation.…”

“… 21 Soft-tissue irritation has been reported as a complication of FNs in multiple studies, with incidence ranging from < 10% to as high as 52% 22 but is minor in most cases and relieved with implant removal. 8 , 21 , 23 – 25 Proposed risk factors for irritation include bent or prominent nail ends, 22 earlier mobilization of the knee 12 and excessive nail protrusion at the time of implantation. Accordingly, studies have advocated immobilization, 23 leaving < 2.5 cm of nail protrusion, and minimizing bending the ends of the nails outside the bony cortex during insertion and trimming of the nails to help decrease soft-tissue irritation.…”

How Long Do We Need to Restrict Weight Bearing after Fixation of Pediatric Femur Fractures?

“…The treatment of choice for pediatric femur fractures remains dictated by the child's characteristics, the fracture pattern, and the treating surgeon's preferences. While locked compression plate fixation has shown at least twice the stiffness and increased torsional stability when compared with titanium elastic nails, flexible nailing has the advantages of minimal soft tissue dissection, faster operative times, and decreased surgical costs, with equivalent outcomes when used in the appropriate patients [14][15][16]. Plating is accompanied by the potential risks of delayed healing from soft tissue stripping, femoral over-children may diminish the need for restricted weight bearing, similar to the protocol employed for locked intramedullary nailing.…”

Comparative study of titanium elastic nailing v/s dynamic compression plating for the management of fracture shaft of femur in adolescent age group

“…A retrospective study conducted by Sean et al, comparing 3 modalities management of fracture shaft of femur found out that, a significant association was found between treatment type and fracture pattern A higher proportion of spiral fractures and fewer transverse fractures were found in the plate group. 8 The mean time of fracture union radiologically was statistically insignificant, were mean time of union in group A it was 12 weeks were as in Group B it was 13.1 weeks. Study conducted by Kumar et al observed the mean union in TENS group in femur fracture was 13.00±1.37 and another studies observed that union rate in children's managed with DCP to fracture shaft of femur was between 8-11 weeks.…”