pediatric femur fractures

1. Paediatric femur fracture in
preschool children

2. • The acceptable angulation in the coronal and sagittal planes varies
from 300 at birth to 150 at 10 years.
• Rotational malalignment does not remodel
• Limb shortening of up to 15 mm can be compensated in children up
to 12 years of age by growth acceleration

3. Treatment modalities in pediatric femur
fracture
• Conservative
- pavlik harness

5. ESIN
• 1970 : Ender & Simon –Weidner developed elastic intramedullary
nails inserted from medial metaphysis
• 1979 : Nancy group, France developed concept of 2 elastic
intramedullary nails with bilateral metaphyseal insertion
• Principle of biological fixation
- three point fixation
- closed with preservation of fracture haematoma and periosteum
- good rotational and bending stability

7. Ender nail
TEN ( titanium elastic nail ) / Nancy nail

9. Cintean R, Eickhoff A, Pankratz C, Strauss B, Gebhard F, Schütze K. ESIN in
femur fractures in children under 3: is it safe? Eur J Trauma Emerg Surg. 2022
Oct;48(5):3401-3407
• 30 children followed for avg 5 and ½ months
• Retrograde nailing (TEN :1.5- 2.5 mm)
• 3/30 need open reduction
• Post op protocol : FWB
• Mean length of stay was 2.0±1.3 days
• First radiographic consolidation signs were seen after 2.4±0.6 weeks
• Time to full fracture union was 5.5±1.3 weeks
• Implant removal was performed after 3.2±1.3 months (2–8 months)

10. complications
• limb shortening of 1.7±1.4 mm (0.3–3.1 mm) in three cases after
surgery without clinical impact
• One patient at the age of 32 months showed a leg-length discrepancy
of 1 cm in favor of the broken leg
• No delayed or malunion was found.
• No refracture after implant removal occurred.

11. Ramo BA, Martus JE, Tareen N, Hooe BS, Snoddy MC, Jo CH.
Intramedullary Nailing Compared with Spica Casts for Isolated Femoral
Fractures in Four and Five-Year-Old Children. J Bone Joint Surg Am. 2016
Feb 17;98(4):267-75
• 262 patients followed for a mean of 32 weeks ( 104- IMN & 158 – spica cast )
• similar clinical and radiographic outcomes regardless of whether they are treated with immediate spica cast
immobilization or IMN
• In the spica group
- the majority of the twelve complications were related to radiographic alignment or skin concerns
- 3/158 repeat spica application
- 4/158 converted to IMN
• In IMN group
- 4/104 implant related complications
- 1 developed osteomyelitis
- 3 knee stiffness
- 3 rotational malalignment >10 deg
• Need for extra surgery in IMN group for implant removal

12. Assaghir YM. Titanium elastic nail in femur fractures as an
alternative to spica cast in preschoolers. J Child Orthop. 2012
Dec;6(6):505-11.

13. Bopst L, Reinberg O, Lutz N. Femur fracture in preschool
children: experience with flexible intramedullary nailing in 72
children. J Pediatr Orthop. 2007 Apr-May;27(3):299-303
• retrospective analysis of 72 children (mean age, 4.1 years; age range, 1.5 -
5.9 years) with 73 femur fractures treated by means of FIN
• Weight bearing was started at a mean of 16.4 days (range, 1-60 days) after
surgery.
• Follow-up was available in 62 children (mean, 36.7 months; range, 4-124
months).
• Complications
-early distal nail exteriorization in 9 children (12.3%) during the first 10
years of the study.
-> 1 cm of femur overgrowth was noted in 6 children (8.2%).
• Preschool children with femur fracture treated by means of FIN benefited
from short hospital stay, early mobilization and weight bearing

14. Mortier D, De Ridder K. Flexible intramedullary nailing in the
treatment of diaphyseal fractures of the femur in preschool
children. Acta Orthop Belg. 2008 April
• 9 preschool children aged 1.5-6 years. The mean length of
postoperative hospital stay was 4 days (range: 3 to 6). The mean time
to solid callus formation was 2.5 months (range: 2 to 3). Follow-up
was available in all 9 children for a mean period of 18.9 months
(range: 3 to 38). No complications were noted

15. Jauquier N, Doerfler M, Haecker FM, Hasler C, Zambelli PY, Lutz N.
Immediate hip spica is as effective as, but more efficient than, flexible
intramedullary nailing for femoral shaft fractures in pre-school children.
J Child Orthop. 2010
• Group I included 19 children with a median age of 26 months (range 12–46 months). Median
hospital stay was 1 day (range 0–5 days) and casts were retained for a median duration of 21 days
(range 12–29 days). General anaesthesia was used in six children and sedation in four. Skin
breakdown secondary to cast irritation occurred in two children (10.5%). The median follow-up
was 114 months (range 37–171 months). No significant malunion was noted. Group II included 27
children with a median age of 38.4 months (range 18.7–46.7 months). Median hospital stay was 4
days (range 1–13 days). All children required general anaesthesia for insertion and removal of the
nails. Free mobilisation and full weight bearing were allowed at a median of 2 days (range 1–10
days) and 7 days (range 1–30 days), respectively, postoperatively. Nail exteriorisation was noted in
three children (11%). The median followup was 16.5 months (range 8–172 months). No significant
malunion was reported
• Young children with a femoral shaft fracture treated by SCI or FIN had similarly favourable
outcomes and complication rates. FIN allowed earlier mobilisation and full weight bearing.
Compared to SCI, a greater number of children required general anaesthesia. In a pre-school child
with a femoral shaft fracture, immediate SCI applied by a paediatric orthopaedic team following
specific guidelines allowed early discharge from hospital with few complications.

16. ESIN
advantages
• Early mobilization
• Early weight bearing
• Short hospital stay
• Less burden of care on relatives
• Short hospital stay for children
with IM nails reduces cost of
treatment to about one half
compared with in-hospital
traction and cast management
disadvantages
• Surgerical morbidity
• Pin related problems
• osteomyelitis
• Cortical perforation
• Repeat surgery for implant exit

20. Prerequisites
• Traction table ( older children) / radioluscent table
• Carm
• Instruments
- awl / 2.5 mm drill bit ( entry hole )
- T handle (2)
- pliers ( nail bending )
- F tool ( reduction)
- impaction tool & mallet
- cutter
- elastic nails ( titanium / stainless steel )

30. Technical points
• Adequate size of nails
• Both nails of same size
• Entry site symmetrical
• Avoid corkscrew
• Both nails should cross twice with maximum bend at level of fracture
site
• Nail should be seated flush to bone to prevent soft tissue
complications