Femoral shaft fractures represent 1.4%–1.7% of all fractures in children and are the most common paediatric bony injury needing hospitalisation. (1, 2). Two-thirds of these occur in children between the ages of 6 to 18 years old, with males are affected mostly (70%) and motor vehicle accidents the most common mechanism of injury. Child abuse should always be suspected and ruled out, especially in younger children (3).
Treatment options for this age group range between open plating, minimally invasive plating, flexible intramedullary nailing, locked intramedullary nailing and external fixation(4, 5). Neither published evidence nor established global guidelines favour one method over the other. The National Institute for Health and Care Excellence (NICE) of the UK has advised using flexible intramedullary nailing for the ages 4 to 12 years provided that the child’s weight is less than 50kg. In contrast, trochanteric-entry locked intramedullary nailing, or submuscular plating is used more often in children older than 11 years old or heavier than 50 kgs (6).
The AAOS Clinical Practice Guideline on the Treatment of Paediatric Diaphyseal Femur Fractures has presented limited evidence to support the use of flexible intramedullary nailing in the age group 5 to 11 years. There was limited evidence also to support minimally invasive plating, flexible intramedullary nailing (FIN), and trochanteric entry locked intramedullary nailing in the ages over 11 years (7).
Flexible intramedullary nailing, specifically elastic stable intramedullary nailing (ESIN), has been established as a method that entails a shorter operative time, less blood loss and a shorter hospital stay compared to the use of submuscular plates (8-10). Good results are obtained in length stable fracture patterns, patients who are lighter than 50kg and after surgery with an optimal configuration of the nails in the medulla (11, 12). However, some reports have associated flexible nailing with more malunion, delayed weight-bearing and healing, and hardware irritation (13, 14).
Submuscular plating is a more dependable option for fracture fixation in length-unstable or complex patterns and heavier children(15-17). The advantages of plating against FIN have been shown biomechanically, especially with comminuted and length-unstable fracture patterns . The clinical indications for this technique are often extended due to the advantages of achieving better alignment and facilitating earlier weight-bearing(13, 14). Whilst the submuscular plating technique is well described(18), surgical implementation can be challenging from controlling fracture reduction, length and rotation intraoperatively prior to insertion of the plate. Despite a decreased incidence of malunion reported with the classic technique (16, 17), complex and unstable fracture patterns do not always spontaneously reduce on traction. We believe introducing an intraoperative tool to facilitate and control the reduction prior to fixation is paramount.
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