Femoral shaft fractures in children with non-ambulatory neuromuscular disorders can be effectively treated using flexible intramedullary nails

Abstract

Purpose: There is little information in the literature regarding flexible intramedullary nails (FIN) for treating femur fractures in children with neuromuscular disorders. The purpose of this study is to investigate the outcomes of FIN for femoral shaft fractures in non-ambulatory children with neuromuscular disorders.

Methods: A retrospective review was conducted on patients with femur fractures at a paediatric hospital between 2004 and 2018. Inclusion criteria were femoral shaft fracture treated with FIN. Outcomes were compared between patients with neuromuscular disorders (NM group) and a control group of those without neuromuscular disorders.

Results: A total of 37 patients with 37 femoral shaft fractures were studied (12 patients in the NM group and 25 in the control group). All NM group patients were non-ambulatory at baseline. Fractures were length stable in all 25 patients in the control group and in 2/12 (17%) patients in the NM group. All fractures healed in both groups. Three complications (all nail migrations) requiring reoperation before fracture union occurred in the NM group, yielding a major complication rate of 25% (3/12) in the NM group versus 0% (0/25) in controls (p = 0.03). Angular deformity occurred in 5/12 (42%) NM group patients and 1/25 (4%) control group patient (p = 0.009); none required reoperation.

Conclusion: Femur fractures in non-ambulatory children with neuromuscular disorders can be successfully treated with FIN. Angular deformities are common in this population, but had no functional impact in the non-ambulatory NM group patients. Surgeons must also be vigilant for implant prominence and skin breakdown in these patients.

Level of evidence: III.

Keywords: cerebral palsy; femur; femur fracture; flexible intramedullary nail; neuromuscular; titanium elastic nail.

Fig. 1.

Non-ambulatory eight-year-old male with arthrogryposis who sustained a femoral shaft after a sibling jumped on his leg (left). Operative fixation using two flexible intramedullary nails was performed (middle), with some translation but no angular deformity. Radiographs four months postoperatively reveal healing fracture with satisfactory alignment and no angular deformity (right).

Fig. 2

Seven-year-old, Gross Motor Function Classification System V male with spastic quadriplegic cerebral palsy who sustained a femoral shaft fracture during physical therapy with his mother (top). He underwent surgical treatment using two flexible intramedullary nails (middle). Final radiographic follow-up nine months postoperatively shows malunion with procurvatum deformity in the sagittal plane (bottom). The angular deformity was treated with observation and had no functional impact on the patient given his non-ambulatory status.

Fig. 3

An 11-year-old female who fell from her wheelchair, sustained a femoral shaft fracture, and underwent surgical treatment with single flexible intramedullary nail. Final radiographic follow-up five months postoperatively show abundant callus formation and acceptable coronal alignment.