Retrograde flexible intramedullary fixation of pediatric femur diaphyseal fractures: all-lateral entry versus medial and lateral entry point techniques

Background
Femur fractures are the most common orthopedic injury requiring hospitalization in children. Fixation using flexible intramedullary nailing (FIMN) for the treatment of children aged 5–11 years having diaphyseal femur fractures is recommended by The American Academy of Orthopedic Surgeons (Level of Evidence: III, Grade of Recommendation: C). Antegrade placement of ‘C’-shaped and ‘S’-shaped nails, retrograde placement of two ‘C’-shaped nails (CC) through medial and lateral approaches, and retrograde placement of ‘C’-shaped and ‘S’-shaped nails (CS) through a single lateral approach are all nail configurations for FIMN.
Objectives
This study aimed to assess and contrast the clinical and radiological outcomes of fixation of pediatric femoral shaft fractures using paired CC-shaped versus paired CS-shaped flexible nails placed in a retrograde manner.
Patients and methods
In this study, 40 children aged from 5 to 12 years with diaphyseal fracture femur were treated by FIMN in Helwan University and Sheikh Zayed Specialized Hospitals. According to the surgical approach, patients were classified into two equal groups: group (1): retrograde placement of ‘C’- shaped through medial and lateral (ML) approaches (CC) and group (2): 20 patients with ‘C’-shaped and ‘S’-shaped nails (CS) through a single lateral approach (AL). At the end of follow–up, the results were assessed clinically using Flynn’s score and radiographically by plain radiographs.
Results
Among the children included in the study, there were 12 (30%) females and 28 (70%) males. Their ages ranged from 6 to 12 years in group (1) with a mean of 8±1.12 years and in group (2) had a mean of 7.67±2.34 years with a range from 6 to 10 years. The two groups were matched in age and sex (P>0.05). The duration of anesthesia was longer in group (1), 52.78 min as against 45 min in group (2), with a 12 min difference, which recorded a significant difference of P=0.034. Complications were less in the CS group than the CC group. In this study, postoperatively, 40% of the CC group had no pain, while 14% of the CS group had no pain [visual analog scale (VAS = 0)]; 45% of the CC group had mild pain (VAS = 1–3) and 30% of the CS group had mild pain; 5% of the CC group had moderate pain (VAS = 4) and 10% had severe pain (VAS = 5), while the CS group did not show moderate or severe pain.
Conclusion
Both techniques for retrograde flexible intramedullary fixation (CC and CS) provide excellent clinical, and radiological outcomes and a low incidence of complication rate for the treatment of pediatric femur fractures. The CS technique can be a faster operation, but proper technique is critical to reduce the risk of shortening and malunion of pediatric femoral fractures.