Intramedullary Nailing Compared with Spica Casts for Isolated Femoral Fractures in Four and Five-Year-Old Children

Femoral diaphyseal fractures are the most common major pediatric injuries treated by the orthopedic surgeon [1]. They represent about 1-2 % of all bony injuries in children [2]. Seventy percentage of femoral fractures involve the shaft [3]. The cause of these injuries varies with age; in preschool children the most common mechanism is a fall from a height. In children aged 4-12 years accidental injury during sport is the predominant cause [4]. A vast majority of femur fractures in children heal without any longterm sequelae [4]. With better understanding of biology of fracture healing and with advances in fixation methods and operative techniques, there has been a general trend toward operative stabilization of femoral shaft fractures in children. Operative treatment options for femoral fractures in children include plating, rigid intramedullary nailing, flexible intramedullary nailing, and external fixation. However, Martinez [5] reported excessive shortening and angular deformity in around 43 % of their patients treated by an early spica cast. Hughes [6] studied the impact of immediate spica casting on patients and families following femoral shaft fractures. They found that the greatest problems encountered by the family in caring for a child in a spica cast were transportation, cast intolerance by the child, and keeping the child clean [4-6]. Although most authors still recommend conservative methods of treatment in pediatric femur fractures in preschool children, there is still confusion regarding the optimal method for children beyond this age group [7]. In this study we compare two main methods in the treatment of isolated femoral fractures in four and five years old children which are intramedullary nailing and spica casts to assess the best method of management of femoral fractures in this age (Table 1). Abstract


Introduction
Femoral diaphyseal fractures are the most common major pediatric injuries treated by the orthopedic surgeon [1]. They represent about 1-2 % of all bony injuries in children [2]. Seventy percentage of femoral fractures involve the shaft [3]. The cause of these injuries varies with age; in preschool children the most common mechanism is a fall from a height. In children aged [4][5][6][7][8][9][10][11][12] years accidental injury during sport is the predominant cause [4]. A vast majority of femur fractures in children heal without any longterm sequelae [4]. With better understanding of biology of fracture However, Martinez [5] reported excessive shortening and angular deformity in around 43 % of their patients treated by an early spica cast. Hughes [6] studied the impact of immediate spica casting on patients and families following femoral shaft fractures.
They found that the greatest problems encountered by the family in caring for a child in a spica cast were transportation, cast intolerance by the child, and keeping the child clean [4][5][6]. Although most authors still recommend conservative methods of treatment in pediatric femur fractures in preschool children, there is still confusion regarding the optimal method for children beyond this age group [7]. In this study we compare two main methods in the treatment of isolated femoral fractures in four and five years old children which are intramedullary nailing and spica casts to assess the best method of management of femoral fractures in this age (Table 1). Clinical data: History has been taken from the family, including the date of the injury to define the type and mechanism of trauma. Physical examination has been documented.

Radiographic examination:
The patients had the following radiological examinations: An antero-posterior (AP) view of the pelvis and an (AP) and a cross table lateral view of the involved femur. Computed tomography (CT) and magnetic resonance imaging (MRI) was not necessary for any case.

Laboratory investigation:
The patients had the following pre-operative routine lab.
Investigations: Complete blood count and Bleeding profile.

A -For intramedullary nailing:
The patient has been positioned supine on a standard Post-operative follows up: Postoperative radiographs have been requested to check for reduction and nail length. discrepancy and rotational malalignment were performed. Stitches was removed after 10 days. Partial weight-bearing will be allowed after 3-5 weeks, according to the stability of reduction, type of fracture, weight, and compliance of the child. Full weight-bearing will be allowed after union has achieved. Nail removal has been done at least 7 months after surgery. 95 less than 15° of angulation and less than 2cm of shortening. If reduction is not acceptable, the spica cast has been reapplied after.

Results
A total of 100 patients diagnosed with and treated for isolated femoral fracture were evaluated throughout this study. Fifty patients were treated with elastic nail fixation ( Figure 1) and another fifty remanipulation. The spica cast has been kept in place for 4-8 weeks.

Follow up
The patients were followed until full union and walking undependably occur which may take from two to six months. follow-up, we documented the range of motion of the hip and knee, evidence of soft tissues irritation by nail ends, length discrepancy (measured by a tape from the anterior superior iliac spine to the medial malleolus), rotational alignment (by comparing hip rotation to the normal side), infection, gait, and status of weight-bearing.
Radiographs were requested to document union, mal-union, nail position, and remodeling. Fracture union was defined as the ability to fully bear weight (or resume previous level of activity for nonwalkers) without pain in the presence of bridging callus on at least three cortices. Delayed union was defined as the persistence of bone pain and tenderness 3 months after the reduction without complete radiological union. Non-union was defined as absence of osseous union more than 6 months after injury. Nail removal was done when the fracture line completely disappeared on radiographs.

Statistical analysis
The data are shown in the form of mean ± standard deviation (SD) and range. All statistical analyses were done using the SPSS year-olds are generally managed operatively, so we narrowed the age range for our investigation to 4.0 to 5.9 years of age.
The mechanism of the injury, fracture location and fracture types of groups are listed. No significant difference was determined when the groups were compared according to these parameters.
When the groups compared, the spica cast group was found to have a shorter duration of hospital stay (1 ± 1) compared with elastic nail group (3 ± 2). The knee range of motion of the spica cast group (132° ± 4) two (months after operation) was found to be better compared with the elastic nailing group (129° ± 5) (after removal of the cast). The elastic nailing group was found to have started walking earlier both with and without support ( Table 2).
Patients with intramedullary nailing started to walk with aid after one month and independently after 2 weeks. Patients with spica cast start to walk with aid after 2 months and independently after 12 weeks.

Discussion
The Mansour [8] compared spica cast placement in the emergency department versus the operating room, and concluded that the outcome and complications were similar, but the children treated in the operating room had longer hospital stays and significantly higher hospital charges [8]. Cassinelli [9] treated 145 femur fractures, all in children younger than age 7, with immediate spica cast application in the emergency department. All children younger than 2 years of age, and 86.5% of children of ages 2 to 5 years old, met acceptable alignment parameters on final radiographs [9].
Rereduction in the operating room was needed in 11 patients.
The investigators concluded that initial shortening was the only independent risk factor associated with lost reduction [9]. The b) The initial treatment should be permanent where possible.
c) Perfect anatomic reduction is not essential for perfect function.

d)
Restoration of alignment is more important than fragment position. e) Overtreatment is usually worse than undertreatment.
f) Immobilise/splint the injured limb before definitive treatment.
Femur fracture is the most disabling fracture in children.
Children at school age are treated using various methods, such as compression plating, submuscular plating, locking bridge plates, rigid intramedullary nails . stainless steel or titanium elastic nails, and external fixators [11]. Preschool children are usually treated with traction, immediate spica cast, or traction then delayed spica cast. Although they produce very good union rates, their disadvantages include loss of reduction requiring repeated adjustments under anesthesia, prolonged immobilization, high malunion rate, compartment syndrome, and Volkmann's ischemic contracture [12].
The care for the child in spica is particularly troublesome.
External fixation has been used in children as young as 3 years of age and, despite the simplicity of its insertion, it is cumbersome and has many complications, such as pin tract infection, which might lead to septic shock , limitation of knee motion, refractures of up to 21.6 % , ugly scars, and the need to apply plaster spica after removal in some cases [13], There are no reports of rigid intramedullary nailing in preschool children because of the risk of avascular necrosis of the femoral head and coxa valga [14]. Minimally invasive submuscular and bridging plating for preschool children has been successful. It offers more rigid fixation than flexible nails, which is reflected in This minimally invasive technique requires short hospital stay compared to other methods of treatment, and this series proved that it can be done with minimum hospital stay, as most children were discharged on the day of surgery [15]. Preschool children constituted a small number of patients treated in many series, but, to the best of our knowledge, only five articles have specifically addressed this age group and only three of them were about elastic nailing. The children studied were treated using the one-surgeonone-technique approach, which would give a better assessment of the results [15].

External fixators were reserved for open fractures of grades
II or III (Gustilo's). Plating was also reserved for comminuted fractures where restoring and retaining the femur length would not be feasible with elastic nails and for solid malunion where an open osteotomy is required [15]. A rigid nailing option is not on the table in these young femurs, so we were left with two options for fractures without inherent instability: spica cast and TEN. Our choice of TEN was based on frequent complications of spica cast, lack of ideal cast care in rural communities which constitute the main referral base of our institution, choice by the child's parents, and the better results of TEN compared to spica [16]. We limited our indication to TEN to non-comminuted fractures to avoid collapse at the fracture site with subsequent shortening and angulation, which occurred in 10 out of 15 unstable fractures in Sink et al.'s series [15]. So IMN in four and five year old children in our study and in other studies has achieved good results in comparison to spica cast and other methods of fixation [17].