Broken bones are a common calamity among children. But young children seem to have an amazing ability to heal and heal well. Fractures of the femur (thigh bone) become more problematic as children get older, larger in size, and heavier.
Studies have been done in younger children with femoral fractures to determine the best way to surgically restore bone alignment with pins, nails, plates, and screws. But surgeons can’t rely on that data when working with older children and teens.
In order to find the optimal way to hold the broken pieces together in more complex femoral fractures in teens, surgeons from The Hospital for Sick Children in Toronto, Ontario (Canada) conducted this study. They went back into their medical records and pulled the medical records of all children ages 11 to 18 who had traumatic femoral fractures.
They compared the results of treatment based on four different ways to surgically fix (hold in place) the broken bones. The four methods of fixation included: 1) elastic stable intramedullary nail fixation, 2) external fixation, 3) rigid intramedullary nail fixation, and 4) plate fixation.
Results were measured using length of hospital stay, time to heal (bone union), development of complications, and the need for a second operation. X-rays taken at the time of surgery and postoperatively were reviewed. They also looked at the type and number of complications associated with each fixation method.
Complications included things like infection, refracture, delayed union, malunion, shortening or lengthening of the bone, and loss of reduction. Loss of reduction means that the bones shifted apart after the fractured edges were brought back together and held in place with hardware.
Choice of fixation method is always left up to the surgeon. There isn’t a protocol or set of rules to say, Use this one or that one based on specific patient factors. Each surgeon evaluates the individual patient and takes into consideration the type of fracture, severity of fracture, age, and weight. Surgeon experience and expertise is also a factor as is parent/family preferences.
We will cut to the chase and tell you that in the end, the study did not yield enough information to make specific recommendations of when and how to use fixation for femoral fractures. But don’t go away — there are a few conclusions offered by the authors.
First, all four types of fixation methods did yield equally satisfactory results. The one method that seemed to have the highest number of complications was external fixation. With external fixation, there are pins through the skin and muscle into the bone. Pins are placed above and below the fracture site with a rigid bar outside the body holding the bone in place.
Fractures treated with external fixation took much longer to heal. That finding doesn’t necessarily mean surgeons shouldn’t use external fixation in adolescents with femoral fractures. This particular complication could be the result of the treatment method, but it could also reflect the fact that this type of fixation is used for the more severe (open) fractures. And we know that open fractures (bone broken and protruding through the muscle and skin) take longer to heal than closed fractures (bone broken but not displaced through the skin).
Another finding from this study was that titanium elastic nails worked just as well as more rigid methods of fixation. This was true even for the heavier teens who weighed as much as 225 pounds. The types of complications that occurred with elastic nails (e.g., loss of reduction, delayed union, refracture) were considered preventable.
In conclusion, the authors suggest that there just isn’t one way to hold femoral fractures together for every adolescent with this problem. Each method has its own advantages and disadvantages.
It’s good to know that external fixation had the highest rate of complications and rigid intramedullary nails (placed down inside the shaft of the bone) had the fewest problems. Surgeons can take this information into consideration when making their decisions about what type of fixation to use on a case-by-case basis.