Femoral beam fracture is the commonest major pediatric orthopedic injury requiring hospitalization. Controversy persists regarding management of femoral fractures in the patients aged between 5–15 years. 11 patients were followed up for the think of period of 12 months and evaluated using Flynn ’ s criteria. All the fractures united between 8–12 weeks. 3 patients had knee severity, 1 affected role had shortening > 2 curium and 1 had superficial infection. We conclude that TENs is simple, rapid & effective discussion for move pediatric femoral shaft fractures between 5–15 years of age with very less complication pace.


Pediatric femoral shaft fractures, Titanium elastic nails, Percutaneous

1. Introduction

Femoral shot fracture is the most common major pediatric orthopedic injury requiring hospitalization. It represents about 1.6 % of all the osseous injuries in children ( Including sub-trochantric & inter-trochantric fractures ). They are more coarse in boys than girls ( 2.6:1 ). 1 There is a little disagreement concerning the discussion of long bone fractures in children less than 5 years i.e with pelvis spica application and adolescents older than 15 years i.e with interlocking intramedullary collar. But controversy persists regarding the patients aged between 5–15 years, with respective available options like traction followed by hip spica, external obsession, compromising stable intramedullary nails ( Ender or titanium ), plate obsession, and locked intramedullary nail down with no clear consensus for the prefer treatment. 2 Over the past two decades the advantages of fracture fixation and early on mobilization has been increasingly recognized. thus there is increasing course towards inner obsession of the pediatric femoral fractures. In 1882 Mataizeau & his team from France developed and revolutionized the technique of elastic stable intramedullary trap ( FSIP ) using titanium pins which is nowadays popularly known as TENS has become the choice of running management for pediatric femoral rotating shaft fractures. 3 The purpose of this prospective study is to evaluate the results of treatment of pediatric femoral quill fractures with titanium rubber band nails ( TENs ) .

2. Materials and methods

Study was conducted at tertiary care center from Jan 2012 to Dec 2014. Patients aged between 5 years to 15 years with femoral shaft fractures both closed and open were treated with close reduction and inner arrested development with titanium elastic nails ( TENs ) ( ). Patients with extreme point proximal or distal femoral fractures closer to the epiphyseal plate ( 10cm ), patients with grade III C open femoral fractures and patients with pathological fractures were excluded from the study. The pre-operative radiogram were evaluated to determine the localization and model of the fracture .Fig. 1Open in a separate window

2.1. Surgical technique

Two retrograde TENs were used in all femoral fractures. A grip table was used for all the patients. Intra-operatively fracture was reduced under roentgenogram persona intensifier. A 1-2-cm longitudinal clamber incision was made over the median and lateral surface of the distal femur, starting 2 curium proximal to the distal femoral epiphyseal plate and introduction was made in the femur with the help of bone owl. A proper sized nails ( not less than 40 % of the narrowest diameter of the diaphysis ) were used. To achieve full three point contact the TENs are pre-bent over the length of the bone three times the diameter of the medullary canal. Nail was introduced with a T-handle by rotation movements of the wrist. Under image intensifier dominance, the collar was driven with rotatory movement or with a malleus to the fracture site which was aligned to anatomical reference or near anatomic position and the complete was advanced to the proximal fragment. At the same time the second breeze through was advanced to enter the proximal break up from the other entry point and in the meanwhile any traction was released to avoid any distraction ( ). Fracture reduction was checked under prototype intensifier, end of the nail down were buried and wound closed .Fig. 2Open in a separate window Post operatively patients were kept in resistless position and above knee poultice slab was applied. This above stifle plaster slab was kept for 2 weeks for rotational stability of fracture as elastic nails as per our opinion does not provide sufficient rotational stability. This plaster was removed after 2 weeks as the fracture gets sticky and therefore TENS alone can provide sufficient constancy at this point. antibiotic prophylaxis was given for 3 days. Knee mobilization started after removing the slab. Non weight bearing mobilization with walker was started from 2nd post op day or as per tolerance of the affected role. Patients were kept not slant bearing till 4 wks and overtone weight bearing was started from 4 wks. complete weight bear was allowed after osseous union. Study was conducted in department of Orthopedics between Jan 2011 to Sep 2012. Thirteen less than 7 days old pediatric femoral shaft fractures in 12 patients ( 10 boys & 2 girls ) were fixed with titanium elastic nails ( TENs ). 10 fractures were closed and 3 fractures were open ( Grade I, II and IIIa ; Gustilo-anderson type ). There were 6 leave sided, 5 right sided and 1 patient had bilateral femoral shaft fractures. operation was performed within 3 days of hospital entrance fee. Results were evaluated using Flynn ’ s scoring criteria 1 ( ) & radiological union was assessed by Anthony et aluminum 4 scale for grading callus formation ( ) .

Table 1

Poor results Satisfactory results Excellent results
Limb length inequality >2cm <2cm <1cm
Mal-alignment >10 degrees 10 degrees 5 drgrees
Pain Present None None
Complication Major & lasting morbidity Minor & resolved None

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Table 2

Grade 0 No identifiable fracture healing
Grade 1 Primary bone healing with little or no new bone formation
Grade 2 Periosteal new bone formation on two sides of femur
Grade 3 Periosteal new bone formation on three or four sides of femur

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3. Results

eleven Patients ( 9 boys and 2 girls ) were available for follow up. The prevailing mode of injury was due to road traffic accident ( RTA ) ( 55 % ). Right-sided involvement was seen in 5 cases ( 45 % ) and left english in 6 cases ( 55 % ). Mid-diaphyseal fracture of femur was found in 8 patients ( 73 % ), 2 patients ( 18 % ) had fracture in distal one-third of femur and 1 affected role ( 9 % ) had sub-trochanteric femoral fracture. 6 patients ( 55 % ) had cross fracture, 3 patients ( 27 % ) had oblique fractures, 1 patient ( 9 % ) had gyrate fracture and 1 affected role ( 9 % ) had butterfly fragment ( comminuted ). Patients were followed up for the mean period of 12 months ( 6 months -18 months ). All the fractures united radiologically between 8 weeks to 12 weeks ( beggarly 9 weeks ) ( ). Full weight bear was possible after 12 weeks after surgery ( ).

Fig. 4Open in a separate windowFig. 3Open in a separate window

Table 3

(a) Gender
9 (82%)
2 (18%)
(b) Side involved
5 (45%)
6 (55%)
(c) Type of Fracture (Gustilo and Anderson)
 Closed Fracture
 Grade I open
 Grade II open
8 (73%)
1 (9%)
2 (18%)
(d) Type of fracture (Configuration)
6 (55%)
1 (9%)
1 (9%)
(e) Mean Age 10.3 years

Open in a separate window average operate time was 50 min and average hospitalization time was 6 day. Results were excellent in 6 patients, satisfactory in 4 patients & poor people in 1 patient according to Flynn ’ s scoring criteria. 3 patients had post private detective stifle severity as the patients did not co-operate for knee mobilization exercises in early on post operative period and evening after removal of boot and bar poultice at 2 weeks. So patients were put on regular physical therapy including continues passive motion ( CPM ). All the patients regained arrant scope of knee gesticulate after average duration of 2 weeks of physical therapy and none of the patients had residual stifle stiffness. One patient had shorten of more than 2 curium, this patient had a spiral fracture and the affected role started burden bear early. One patient had superficial infection at submission web site which healed on regular stuffing & antibiotics besides two patients had dangerous bark annoyance at submission site for which the complete had to be removed after 6 months in 1st shell and 7 months in 2nd case. There were no instances of osteitis or septic arthritis, rotational deformity, or pneumonic embolism, there was besides no re-fracture after nail removal and no indigence for any junior-grade surgical procedure or readmission after discharge, except for nail down removal (, ) .

Table 4

Variable Value
(a) Mean duration of hospital stay 6 days
(b) Mean time for radiological union 10.5 weeks
(c) Flynn’s criteria results
Excellent 6 (55%)
Satisfactory 4 (36%)
Poor 1 ((%)

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Table 5

Sr. no Age Sex Side Type of fracture Type of fracture Mode of trauma Hospital stay LLD Time of radiological union Flynn’s criteria results
1 12 Male Right Closed Transverse Fall from height 4 days None 10 weeks Excellent
2 9 Male Right Closed Transverse RTA 5 days 0.5 cm 8 weeks Excellent
3 8 Male Left Closed Oblique RTA 8 days 1 cm 12 weeks Satisfactory
4 6 Female Left Grade I open Comminuted Fall at home 9 days 1 cm 10 weeks Satisfactory
5 10 Male Left Grade II open Spiral RTA 5 days 2 cm 12 weeks Poor
6 6 Male Left Closed Transverse RTA 6 days None 10 weeks Excellent
7 14 Male Right Closed Transverse Fall from height 7 days 0.5 cm 12 weeks Excellent
8 15 Male Right Closed Transverse RTA 6 days None 12 weeks Excellent
9 15 Male Right Grade II open Oblique RTA 5 days 1 cm 12 weeks Satisfactory
10 7 Female Left Closed Transverse Fall at home 4 days None 8 weeks Excellent
11 11 Male Left Closed Oblique Fall from stairs 6 days 0.5 cm 10 weeks Satisfactory

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4. Discussion

Over the past 20 years, pediatric orthopedic surgeons have tried a assortment of methods to treat pediatric lower arm fractures to avoid prolong immobilization and complications. Each method acting has had its own complications : spica cast immobilization alone or following traction had resulted in limb-length discrepancy, angulations, rotational deformity, psychological and economic complications. 5, 6 External fixation had resulted in pin-tract infection, loss of stifle scope of gesture, delayed union, non-union, and refracture after fixator removal. 7, 8 Solid antegrade intramedullary nail down had resulted in avascular necrosis of the femoral drumhead, trochanteric epiphysiodesis, and hip valga. The ideal device to treat pediatric femoral and/or tibial fractures should be a simple, load sharing home splint, allowing early mobilization while maintaining length and alliance for respective weeks until bridging callus forms, without endangering the rake supply to the pineal gland. 1, 2 TENs has all the above properties and thus serves as the ideal implant for pediatric femoral fractures. TENs arrested development was used adenine early as 1982 by french surgeons ; one of the main criticism was the monetary value of treatment. 3 Buechsenschuetz et alabama 2 in their study including 71 femoral shot fractures in 68 patients compared clinical and functional results of 90-90 grip and spica roll with rubber band stable intramedullary pinpoint found no dispute between the two groups for standard clinical/functional criteria but elastic nail down group was associated with a lower overall cost than grip and casting group besides it resulted in better scratch acceptance, and higher overall parent satisfaction. Ligier et aluminum 9 and Flynn et aluminum 1 in their studies have reported that TENs can give rotational stability if good manage is taken intra-operatively during breeze through interpolation and postoperatively, particularly for comminuted, spiral, and long external oblique muscle fractures. Gamal EL-ADL et alabama 10 in their prospective clinical survey to assess the results of operative treatment of pediatric femoral and tibial fractures found that the average hospital stay was 5.7 days and most of the fractures united within 3 months. mean time to bone healing was 85 days, with a range between 42–140 days and thus concluded that titanium rubber band breeze through fixation is a dim-witted, easy, rapid, authentic and effective method for management of pediatric femoral and tibial fractures between the long time of 5 to 16 years, with shorter surgical time, lesser blood less, lesser radiation exposure, shorter hospital stay, and reasonable time to bone bring around. L A Moroz et aluminum 11 assessed a total of 229 children with 234 fractures of the diaphysis of the femur retrospectively, clinical assessment included the range of drift in the hip and knee, rotational alignment, meter to weight bearing and nail removal, signs of aggravation or local infection from the point of the collar, and signs of deep infection and post-operative complications besides radiological judgment included an assessment of the status of the collar, frontal and sagittal alignment, loss of reduction, callus formation, disturbance of trochanteric emergence, osteonecrosis of the femoral fountainhead and femoral length. Varus and valgus angulation was measured from the anatomic axis and concluded that Titanium elastic complete is presently the most popular method for treating fractures of the shaft of the femur in children of school age, and confirmed that the result after treatment is excellent or satisfactory in most patients. The results of the present series are comparable to those of the other series on management of femoral quill fracture in children ( ). It has definite advantages over the other techniques that have been used in the management of pediatric femoral cheat fractures. celebrated advantages of this technique are early union ascribable to micro-motion at fracture site, early mobilization, early weight bear, scar acceptance and high affected role and parent satisfaction rate. Be-sides these TENs due to its retrograde introduction do not injure or affect either the epiphysis or the blood provide to femoral lead. The excellent biocompatibility and elasticity of titanium have far enhanced the utility of TENs. More importantly elasticity promotes callus formation by limiting stress shielding frankincense leading to early weight yield and faster union.

Table 6

Study Number of patients Hospital stay in days (Mean) LLD Time for bony union (Mean) Flynn’s Score
Excelle-nt Satisfactory Poor
Gamal El-ADL et al.
66 (73 fractures) 5.7 None 12 weeks (85 days) 75.8% 24.2% 0
Sakia et al.
22 (22 fractures) 9.8 3 (1.5 cm or less) 8.7 weeks 13 (59%) 6 (27.2%) 3 (13.6%)
Roop singh et al.
35 (35 fractures) 12.3 3 (1 cm or more) 9.6 weeks 25 (71.4%) 8 (22.8%) 2 (5.8%)
Hassan Al-Sayed et al.
25 (25 fractures) 12 5 (1.5cm or more) 9 weeks
L A Moroz et al.
229 (234 fractures) 150 (65%) 57 (25%) 23(10%)
Nishikant Kumar et al. (2010) 20 (20 fractures) 4 (1 cm or more) 8 weeks
Present study 11 (11 fractures) 6 1 (2 cm or more) 9 weeks 6 (55%) 4 (36%) 1 (9%)

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5. Conclusion

frankincense we conclude that Titanium elastic smash is dim-witted, rapid & effective treatment for displace pediatric femoral spear fractures between 5–15 years of long time with very less complication pace. It besides reduces the hospital stay and helps in early mobilization of children .

Conflict of interest

There is no conflict of sake or any fiscal gains from anywhere for conducting this discipline .


☆Work carried out at– Mahatma Gandhi institute of aesculapian sciences, Sewagram .

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