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Pediatric Femoral Shaft Fractures

A Multicenter Review of the AAOS Clinical Practice Guidelines Before and After 2009

Roaten, John D. MD*; Kelly, Derek M. MD*; Yellin, Joseph L. MD; Flynn, John M. MD; Cyr, Micaela BA; Garg, Sumeet MD; Broom, Alexander BA§; Andras, Lindsay M. MD§; Sawyer, Jeffrey R. MD*

Journal of Pediatric Orthopaedics: September 2019 - Volume 39 - Issue 8 - p 394–399
doi: 10.1097/BPO.0000000000000982

Background: To determine if the AAOS clinical practice guidelines (CPG) for the treatment of pediatric femoral shaft fractures (2009) changed treatment, we analyzed pediatric femoral shaft fractures at 4 high-volume, geographically separated, level-1 pediatric trauma centers over a 10-year period (2004 to 2013).

Methods: Consecutive series of pediatric femoral shaft fractures (ages, birth to 18 y) treated at the 4 centers were reviewed. Treatment methods were analyzed by age and treatment method for each center and in aggregate.

Results: Of 2646 fractures, 1476 (55.8%) were treated nonoperatively and 1170 fractures operatively. Of the operative group, flexible intramedullary nails (IMN) were used for 568 patients (21.5%), locked intramedullary nails (LIMNs) for 309 (11.7%), and plating for 188 (7.1%). In total, 105 fractures were treated with external fixation or skeletal traction. Analysis before and after the CPG publication revealed a significant increase in the use of interlocked IMNs in patients younger than 11 years (0.5% before, 3.8% after; P<0.001). Over the same time period there was an increase in surgical management, regardless of technique, for patients younger than 5 years (6.4% before, 8.4% after; P=0.206). There were considerable differences in treatment among centers: 74% of fractures treated with plating were from a single center (center A), which also contributed 68% of patients younger than 5 years treated with plating; center B had the highest rate (41%) of flexible IMN in children younger than 5 years; center C had the highest rate (63%) of LIMN in children younger than 11 years; and center D treated the fewest patients outside the CPG guidelines.

Conclusions: Following publication of the AAOS CPG, there was a significant increase in the use of LIMNs in patients younger than 11 years old and a trend toward surgical treatment in patients younger than 5 years. The considerable variability among centers in treatment methods and adherence to the CPG highlights the need for further outcome studies to better define optimal treatment methods and perhaps update the AAOS CPG guidelines.

Level of Evidence: Level III—therapeutic.

*Department of Orthopedic Surgery, Le Bonheur Children’s Hospital, University of Tennessee-Campbell Clinic, Memphis, TN

Harvard Combined Orthopaedic Residency, Boston, MA

Children’s Hospital of Colorado Orthopedics Institute, University of Colorado, Aurora, CO

§Children’s Hospital of Los Angeles, Los Angeles, CA

J.D.R., J.R.S., D.M.K., J.L.Y., J.M.F., M.C., S.G., A.B., L.M.A.: substantial contributions to the conception or design of the work; acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Each person listed as an author has fulfilled the criteria for authorship as established by the ICMJE.

No external funding was received for this study.

The authors declare no conflicts of interest.

Reprints: Jeffrey R. Sawyer, MD, Department of Orthopedic Surgery, Le Bonheur Children’s Hospital, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104. E-mail:

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