Management of femoral shaft fracture in children by using minimal invasive plate M.A.Mikhael, A.I.Ali and M.M.El Karmany

Background: Pediatric femoral shaft fracture is a common injury. Casting, external fixation, elastic intramedullary nail, intramedullary nails, compression plating and submuscular plate have all been used as a treatment option. However, The treatment of pediatric femoral shaft fractures, particularly in the 6 to 13 year age group, has in recent times moved away from the traditionally conservative approach to a more surgical one. Depending on the fracture pattern, patient age and other patient and economic and psychological factors, several different methods of fixation are available, including  flexible intramedullary nailing, external fixation, open compression plating, lateral entry intramedullary nails and submuscular bridge plating. The aim of the study was to evaluate the outcomes as well as advantages of minimally invasive bridge plating of femoral shaft fractures in children between 6 and 12 years of age. Methods:  It is a comprehensive prospective case series study. It was conducted at Trauma unit Al Eman general hospital, Assiut, Egypt.  All children between the ages of 6 and 13 who were admitted to the orthopedic department with femoral shaft fractures, were asked to participate in the study. Results: The mean operating time for the index procedure in this study was 62±20.6minutes with the average total incision length being 11.3±2.7 Cm and average radiation exposure of 59±25seconds. We found the average blood loss during the index procedure to be 99.7±34.4 ml (60-200ml) with no requirements for blood transfusions exceoy . All fractures in our series united by 5-9 weeks with mean of 6.6±1.1 week  post-surgery. Plates in our series were removed at an average of 9.8±1.4months. The average surgical time was 35±3 minutes and blood loss 48 ml. At final follow up (9 month) there was no significant difference between the operated and non-operated sides in terms of leg length discrepancy; range of motion of the hip and knee as well as alignment in the axial and coronal planes. In our view external fixation should be reserved for polytrauma patients or in patients with high-grade open femur fractures. The technique of femoral shaft plating has evolved with a better understanding plate mechanics. This series indicates that submuscular bridge plating is an alternative to treat length unstable femoral fracture  lit makes use of a minimally invasive technique with resultant small well-accepted scars and does not disrupt the fracture biology. It allows for early mobilization and discharge. Bridge plating was performed in 30 patients in this study with good results. The reduction was maintained and all fractures went onto complete union within 3 months. There were no symptomatic malalignments or leg length discrepancies and all patients returned to full activities. The 1 major complication of rotational malalignment was due to a preventable technical error. Conclusion: This series provides evidence supporting the use of submuscular bridge plating in length-unstable femoral shaft fractures in children between the ages of 6 and 12 and the Cluster technique simplifies application of the screws through the small incisions. From this study cluster technique gives good stability for healing of pediatric fracture shaft femur.