American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines for pediatric femoral shaft fractures indicate titanium elastic nails (TENs) for children 5 to 11 years old. Growing evidence suggests these fractures may also be treated with open or submuscular plating. The purpose of this study was to compare estimated blood loss (EBL), operative time, fluoroscopy time, cost, and subjective and objective pain scores between TENs and plating techniques used in 5- to 11-year-old children with midshaft femur fractures based on length stability. We hypothesized that EBL, operative time, and fluoroscopy time would be greater and pain would be lower with plate fixation.
We retrospectively identified all pediatric midshaft femur fractures treated with TENs, submuscular plating, or open plating between 2004 and 2014. Demographic, injury, and surgical data were obtained for analysis. Cost data were obtained from Synthes Inc. Outcomes were determined using the TEN outcome scoring system. Variables were compared between the 3 fixation methods using paired t tests or Fisher exact test as appropriate. Cost data were compared with Mann-Whitney nonparametric test.
There were 65 midshaft femur fractures in 63 patients included. TENs accounted for 77% and plating 23%. There were no statistical differences in injury severity score, length of stay, length unstable fractures, open fractures, fluoroscopy time, or pain. However, there was a significantly greater operative time (P=0.007) and a notably greater EBL (P=0.057) for the plating technique compared with TENs. Patient outcomes were found to be equivalent. Implant cost was not significantly different although increased surgical costs were seen in plating (P=0.0007).
This study supports the use of TENs or plating for midshaft femur fractures in children 5 to 11 years old, regardless of length stability. The use of plates resulted in higher EBL, longer operative time, increased cost, and equivalent pain compared with TENs. To our knowledge, this study represents the first direct comparison of the common fixation methods specifically for midshaft femur fractures and favors the use of TENs.
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