Predictors of Open Reduction in Pediatric Femur Fractures Treated With Flexible Nails

Abstract

Background: Closed reduction (CR) is sufficient to reduce the majority of femur fractures treated with flexible intramedullary nailing (FIN). No previous study has examined factors associated with failed CR of pediatric femoral shaft fractures treated with FIN. We sought to determine preoperative factors associated with failed CR. We hypothesized that fracture, patient, and surgeon characteristics would impact the need for open reduction (OR). Methods: A retrospective review of children treated for femur fracture between 2012 and 2017 at a tertiary pediatric hospital was performed. Comparisons were made between 2 groups: FIN with CR group and FIN that required OR group. Demographic and baseline characteristics were compared between treatment groups using either χ2 tests or Fisher exact tests for categorical variables and general linear models for continuous variables. Odds ratios with 95% confidence intervals were calculated using univariate logistic regression tests. Results: Of 449 consecutive pediatric femur fractures treated at our center, 85 children were treated with FIN and constituted the study cohort. CR failed in 14 patients (16.5%) necessitating OR of the fracture site. Significant differences between study groups were found in fracture location (P=0.018), the mechanism (P=0.003), and displacement on the anteroposterior radiograph (P=0.027). Surgical time was found to be longer in the OR group (P=0.010). We identified 3 preoperative predictors of OR for FIN including fractures caused by high energy mechanisms (odds ratio=7.5), distal third fractures (odds ratio=15.3), and fracture displacement on the anteroposterior view (odds ratio=1.06). Surgeon years in practice, patient weight, age, and time from injury to surgery were not associated with OR. Conclusions: This study presents 3 preoperative risk factors that predict the need for OR of femur fractures treated with FIN. Surgical time was longer in cases that required OR. Our findings suggest that surgeons should avoid lengthy attempts at CR and consider a lower threshold for OR of at-risk fractures or use another technique other than flexible nails. Level of Evidence: Level III—prognostic.

Comparison of Noncontact Plating with Conventional Methods and Osteosynthesis Techniques in the Treatment of Pediatric Femoral Fractures

“…Results: The mean age was 8.3±1.4 (6)(7)(8)(9)(10)(11) in group 1, 10.2±2.2 (7)(8)(9)(10)(11)(12)(13)(14)(15) in group 2, and 9.7±2.8 (7-15) in group 3. The time of union was 8.0±2.2 weeks (6-16) in group 1, 9.7±2.7 weeks (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) in group 2, and 7.1±1.0 weeks in group 3 (6 -9). In group 1, one patient had delayed union, two patients had a valgus deformity, two patients had minor wound site infection, and four patients had shortening of less than 2 cm.…”

“…A study by Heffernan et al emphasized that open reduction should be initiated in case of prolonged closed reduction in elastic nailing in pediatric femoral fractures. The researchers reported that they had difficulty in reduction, especially in overweight and elderly patients 17 .…”

The Feasibility of Utilizing Malunion Criteria to Limit Radiographs After Spica Casting for Pediatric Femur Fractures

“…Other work has assessed preoperative factors associated with difficult operative fixation of pediatric femur fractures. In a retrospective study of 85 children treated with flexible intramedullary nailing for isolated femur fractures, Heffernan et al 12 identified 3 factors (high energy mechanism, distal third fracture location, and initial fracture displacement) that predicted the need for open reduction. This study demonstrated the importance of identifying pretreatment risk factors that may necessitate an alternative technique or treatment plan.…”

Management of Length Unstable Femur Fractures in Children by Flexible Intramedullary Nails: A Systematic Review

“…Length unstable fractures are usually spiral, long oblique or comminuted and are often associated with > 2 cm of shortening, with authors recommending the use of EF and submuscular plating for these fracture configurations in children between 5-11 years of age. However, more recently, some authors have recommended the use of FIN's for the management of these fractures (9,11,22,23).…”