pediatric femoral spear fractures had been traditionally treated with not private detective methods with traction and spica cast application [ 6 – 8 ], however over the past two decades operative treatment has been increasingly tried in order to avoid drawn-out immobilization and early complications of earlier methods. Most democratic of these operative treatments have been inner arrested development with plate [ 25 – 27 ], fixed fixation with intramedullary smash [ 28 ], external fixation [ 29, 30 ] and more recently flexible intramedullary complete [ 24 ]. Each of these methods has its advantages and disadvantages. external fixation has been associated with refracture and pin-tract infection [ 31 ], solid intramedullary nail with avascular necrosis of the femoral head [ 18, 31, 32 ], dilute of the femoral neck [ 21 ] and growth arrest of the greater trochanter with secondary hip valga [ 17, 21 ]. In addition, plating of the femur demands across-the-board soft-tissue dissection and has been related with hardware failure, infection and greater lineage personnel casualty [ 31 ]. flexible intramedullary complete, by allowing micromotion at fracture site, promotes bone healing without violating open physis and, being a close routine, has a gloomy gamble of contagion. elastic nails had been used for fixation of peritrochanteric fractures with some success [ 33, 34 ] but its application for pediatric cheat fractures was popularised by nancy team [ 22 ]. Since then respective authors have reported on the results and complications of this technique. The earlier indication of this technique for femoral shaft fractures was in patients of 6-16 years senesce group but respective authors have reported excellent results in preschool children besides [ 35, 36 ]. possibly running indications for femoral shaft fractures can be expanded to include children of all ages with femoral shaft fractures and open physis. compromising collar for pediatric femoral shaft fractures has yielded predictably excellent union across the literature. Ligier et aluminum reported union in all 123 cases treated with this technique [ 22 ]. Flynn et alabama [ 24 ] ( normality = 58 ) and Narayanan et aluminum [ 12 ] ( north = 79 ) besides did not report any marriage difficulties. Luhmann et aluminum [ 37 ] observed one hypertrophic non marriage in 43 process femoral shaft fractures. postoperative immobilization has been variably used after inner arrested development with flexible nails. Ligier et alabama [ 22 ] did not use any postoperative immobilization in line to selective practice of spica form or stifle immobilisers by Flynn et alabama [ 24 ] ( 41/58 ), Luhmann et aluminum [ 37 ] ( 17/38 ), Moroz et alabama [ 38 ] ( 201/234 ). We used postoperative immobilization in 8 patients lone since adequate fracture constancy was achieved in all early cases. Degree of communition was a clear predictor of use of postoperative immobilization in this series as all such cases were either winquist class III or IV. Although most authors have recommended routine breeze through removal after union however few have recently questioned this practice. Morshed et alabama in a retrospective study involving 25 fractures treated with TENS reported survivorship loose of revision due to pain of 72 % at 5 years follow up [ 39 ]. clock of nail removal after fracture marriage has not been uniform amongst previously published series and there are no well-defined guidelines in literature. Although early removal has led to periodic complication [ 24 ], however many authors have reported satisfactory result even after removal of nails equally early as beginning of third postoperative calendar month [ 22 ]. overall, most authors have typically recommended complete removal after fracture bring around at 6 months to 1 year following operating room [ 39 ]. We did n’t encounter any difficulty in breeze through removal evening after 1 year and routinely advised our patients for this procedure. Three cases refused for nail removal and demonstrated proximal migration of breeze through insertion site ascribable to continue growth from distal femoral physis although it did not result in any long term complication.

It has been recommended that diameter of each pinpoint should measure 40 % of narrowest diameter of the medullary canal [ 24 ] and both nails should be of same diameter [ 12 ]. This recommendation was followed in all our cases although it was not always potential to follow 40 % rule. Use of stainless steel nails has not been recommended in past because of reverence of malunion owing to more severity of sword compared to titanium. This scene has been refuted by Wall et aluminum [ 40 ] who reported higher malunion rates for titanium nails as compared to similarly designed stainless steel nails. In our sketch we did not find any statistically significant difference in rates of minor or major malunions between collar types whereas sword nails were well cheaper than their titanium counterparts. however, there was a significant difference in malunion rates with academic degree of communition at fracture web site. Narayanan et aluminum [ 36 ] and Sink et aluminum [ 41 ] reported exchangeable effect of communition on malunion rates. A patronize complication in this series was skin irritation and pain at nail interpolation site leading to limited range of knee movement which resolved completely after complete removal. similarly high incidence of this minor complication has been observed in former reports [ 12, 37 ]. We observed a significant dispute in rate of this complication between TENS and ender ‘s complete which was related to inclination of leaving pinpoint flush with femoral cortices in latter. This was possibly the resultant role of less apprehension of difficulty in nail retrieval in ender ‘s smash, which has an eye ( fix ) at its end for extraction, as compared to TENS and was not a result of corporeal properties of nails. Narayanan et aluminum [ 12 ] has recommended cutting the ends short and advancing the nails with a excavate tamp down until the ends lay adjacent to the supracondylar flare of the distal femoral metaphysic but this is not universally practiced proficiency [ 24, 37 ]. furthermore, in their series, Narayanan et aluminum [ 12 ] did not remove majority of nails which were cut affluent with cerebral cortex and their opinion regarding relief of complete removal with stream instrumentation can not be validated. holocene initiation of end caps for nails may provide a solution for this problem but our experience with this is not sufficient to make valid notice [ 42 ].

Limb length discrepancy was a frequent but clinically insignificant complication as most fracture limbs were within 1 centimeter in distance of the contralateral normal limb. however, shortening of > 1 centimeter was observed in 5 patients having grad III or IV communition. Although lesser academic degree of limb distance discrepancy is fairly common, however most published articles have reported infrequent happening of clinically significant discrepancy [ 12, 24 ].

Vrsansky et aluminum [ 43 ] reported universally good results in 141 fractures without a individual complicatedness whereas Flynn et alabama [ 24 ] had only one poor solution in 58 fractures. respective other authors have reported variable rates of complications. Sink et aluminum [ 41 ] reported 62 % complication rate necessitate unintentional operation before fracture union in third ( 21 % ) of these cases. The complications in this serial were related to length unstable fractures which were either comminuted or hanker oblique. In hanker devious fractures the distance of the asynclitism was twice a hanker as the diameter of the femur at the charge of the fracture. Comminuted fractures had more than one continuous fracture and a chat up fragment. Luhmann et aluminum [ 37 ] reported an overall complication rate of 49 % ( 21/43 ) but only 2 major postoperative complications with rest being minor complications. Ho et alabama [ 44 ] reported a entire complication rate of 17 %. We had fair share of complications with overall 32 patients reporting significant complication amounting to 44 % complication rate. however despite this eminent rate of complications, there were only 4 poor people results in this series with remaining patients having only minor complications. We conclude that flexible pinpoint for fault cock femur in pediatric long time group yields excellent or satisfactory results in majority of patients with fair complication rates. Furthermore, stainless steel nails produce results similar to titanium nails at well less price .

Consent statement

Written informed consent was obtained from each patient for publication of this report and accompanying images. Copies of written consents are available for reappraisal by the Editor-in-Chief of this diary .

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