Better outcomes seen with submuscular plating vs IM nailing for pediatric femur fractures

Susan Scherl, MD

This study retrospectively reviews a cohort of 198 femur fractures in 196 children aged 8 years and older treated by one of the following three methods: submuscular plating; rigid trochanteric entry nailing; or flexible intramedullary nailing. As the authors note, numerous other retrospective studies of pediatric femur fracture treatment have shown good outcomes with the utilization of each of these methods. However, there have been few papers directly comparing treatments.

This study found all fractures healed, and there were no intraoperative complications in any of the groups. The mean ages of the patients in the flexible nail group and submuscular plating group were younger than those in the rigid nail group, and may therefore be more directly comparable. There was also some variation between the three groups in fracture pattern and site, with a significant association between fracture pattern and treatment option, indicating a non-random distribution of fracture complexity between the three groups.

The main findings of the study were a faster time to healing and quicker return to full weight-bearing in the submuscular plating group. This is not unexpected, as submuscular plating is rigid fixation and there was a higher percentage of spiral fractures, which have a large surface area conducive to rapid healing, in the submuscular plating group. The study also found a statistically significant increase in hardware irritation in the flexible nailing group. Irritation at the ends of the flexible nails is common and is both transient, since it goes away when a bursa forms, and temporary, since most pediatric orthopedists routinely remove this hardware. Finally, the study reports a statistically significant increase in malunion in the flexible nail group. The authors state clear definitions of malunion in the “Methods and Materials” section, as well as ranges for the resultant malunions in the “Results” section. They do not specifically state whether any of the malunions caused cosmetic or functional problems. Four of the 13 malunions in the flexible nail group were in patients in whom the nails were used despite factors known to be associated with poor outcomes for this procedure, such as weight greater than 45 kg, length and unstable fracture patterns.

As the authors note, the outcomes overall for the surgical management of pediatric femur fractures is good. Most pediatric orthopedists, including those who participated in the study, use a variety of different techniques in day-to-day practice, depending on both patient factors and fracture personality. A randomized, prospective study would be necessary to tease out subtle differences in outcome and complications. Such a study would probably need to be multicenter to enroll enough patients to generate sufficient power.