Comparative Study between the Elastic Nail versus Hip Spica Cast in Early Treatment of Pediatric Femoral Shaft Fractures

Introduction: Femoral shaft fractures are among the most common pediatric injury, which have the highest incidence among other pediatric fractures, and treatment of them carries a lot of controversies. Aim of the study: To compare the outcome of fixation of femoral shaft fracture by elastic nail with Spica cast. Patient and method: This prospective comparative study was carried out in Sulaimani Teaching Hospital, in the period from the 10th of December 2011 to the 10th of June 2012, for two groups of children whose ages were between 4 - 12 years (average 6.61 years), sustained traumatic femoral shaft fractures with follow-up period of about 6 months. The first group was consisting of 30 children treated by Elastic Intramedullary Nail, while the second group was consisted of 30 children treated by hip Spica. The selection was made on random bases. Results: Age range was between 4 - 12 years and showed male predominance in both groups with ratio of about 2:1 while fracture site showed predominance of the midshaft pattern in both groups. This study showed highly significant deference (P value of 0.001) between the two groups (Spica group of 3 days versus Nail group median of rate 4.5 days) in the admission period. Our sample showed shortening of about 2 cm in 2 case in the Nail group (6.7%) versus 6 cases (20%) in Spica group. We reported 4 cases of wound infection (13.3%) and 4 cases of pin site irritation (13.3%) in nail group. A higher rate of malunion was observed in the Spica group (10 cases more than 10° angulation in coronal plane) while the Nail group reported 2 case more than 10° in coronal plane. The mean operative time for Nail group was 55 minutes while in Spica group was 30 minutes. We reported shorter time to start mobilization and walking with support or independently in the nail group (weight bearing time 7.2 weeks) compared with the Spica casting group (weight bearing time 7.5 weeks). Conclusion: Elastic nail fixation yields better outcome for femoral shaft fracture in form of easier child handling, parent’s satisfaction, and maintaining acceptable fracture alignment.

Evaluation of the bone metabolism balance and traumatic reaction of minimally invasive mippo intramedullary nail internal fixation treatment of femoral shaft fractures

Objective:To evaluate the bone metabolism balance and traumatic reaction of minimally invasive mippo intramedullary nail internal fixation treatment of femoral shaft fractures. Methods:80 patients with femoral shaft fractures who were treated in our hospital between May 2011 and December 2016 were collected and divided into control group (n=40) and observation group (n=40) according to random number table, control group received conventional steel plate internal fixation treatment, and observation group received minimally invasive mippo intramedullary nail internal fixation treatment. Differences in serum levels of bone formation indexes, bone resorption indexes, inflammatory factors, and pain mediators and so on were compared between two groups of patients before operation and 1 week after treatment.Results: Before operation, differences in serum levels of bone formation indexes, bone resorption indexes, inflammatory factors and pain mediators were not statistically significant between two groups of patients. After operation, serum bone formation indexes P ICP, BGP, BALP and ALP levels in observation group were higher than those in control group;serum bone resorption indexesβ-CTX and OPG levels were lower than those in control group;serum inflammatory factors IL-1β, IL-6, IL-8 and CRP levels were lower than those in control group;serum pain mediators SP, PGE2 and 5-HT levels were lower than those in control group.Conclusion:Minimally invasive mippo intramedullary nail internal fixation treatment of femoral shaft fractures can promote the bone formation, relatively inhibit bone resorption and cause less traumatic reaction.

Epidemiological Pattern of Closed Femoral Shaft Fractures in a Regional Tertiary Hospital in Enugu, Nigeria

Background: The femur is the longest and strongest tubular bone in the human body. The femoral shaft is the portion of the bone between 5 cm distal to the lesser trochanter and 6 cm proximal to the most distal point of the medial femoral condyle. Femoral shaft fractures often result from high energy forces. These fractures occur mostly among young adults. Objective: This was to determine the epidemiological pattern of closed femoral shaft fractures in a regional tertiary hospital in Enugu, Nigeria. Method: The study was a prospective study over a 12 month period (June 2015-May 2016) at National Orthopaedic Hospital, Enugu. Following ethical approval and written informed consent, patients were consecutively recruited. The patients were clinically and radiographically evaluated at presentation. The diagnosis of closed femoral shaft fractures were made from the physical examination finding of absent open wound communicating with the fracture hematoma in the thigh and anteroposterior (AP) and lateral x-rays of the affected thigh confirming the fracture pattern. The data collected included patients’ demographics, the cause of injury, the side of injury and anatomic site of the injury among other parameters. The data were collected using well designed and structured proforma. Results: A total of 52 femoral shaft fractures in 50 patients were included and analyzed using SPSS version 20.0. The age range of the patients is 18 - 85 years with a median age of 39.1 ± 14.9 years. The most commonly affected age group is 21 - 30 years. There was male preponderance with a male to female ratio of 2.3:1. Majority of the fractures (76.9%) resulted from road traffic crashes most commonly following motor vehicular accident (36.5%). Majority of the fractures (92.3%) are unilateral with right side to left side ratio of 1.2:1. Majority of the patients (51.9%) had Winquist Hansen grade III type of fracture. The most common associated injury is fractures of tibia/fibula followed by fracture of the neck of the ipsilateral femur. All the patients were treated operatively using either locked intramedullary nailing technique or plating technique. Majority of the patients (59.6%) were discharged between 10th and 29th day post-operatively. Conclusion: From the results of this study, it is concluded that most of the closed femoral shaft fractures were caused by high energy trauma from road traffic crashes. It is therefore recommended that proper education of motorists on good use of roads and strict adherence to traffic rules will significantly help in preventing the occurrence of these fractures in our environment.

A Finite Element Model of Locked Plating in Femoral Shaft Fractures

Introduction: The Locking Compression Plate (LCP) system is a versatile technology that can be used either through conventional compression plating techniques or as an internal fixator with locking head screws. There have been only a few biomechanical studies examining the role of locked screw configuration on construct stability with most recommendations based upon empirical evidence or data from compression plating. This study will attempt to determine how different locked screw configurations, fracture gaps (distance between bone fragments), and interface gaps (distance between plate and bone) will affect the peak stress(von Mises stress) experienced by the plate-screw construct and, thereby, look at ways to minimize the risk of hardware failure. Materials Methods: A finite element model (FEM) was developed of a transverse mid shaft femoral fracture bridged by an eight-hole titanium LCP. Seven different screw configurations were investigated. Three different fracture gaps and three different interface gaps were studied as well. Results: The 1368 configuration was found to experience the least peak stress of 2.10 GPa while the 2367, 2457, and all filled configurations were found to have the highest peak stress (25.29 GPa, 22.78 GPa, and 23.54 GPa, respectively). Peak stress increased when the interface gap increased. Peak stress also increased as the fracture gap increased, with the largest jump between the 1 mm and 2 mm gaps. Conclusions: Every fracture is unique, and has a vast amount of parameters that must be considered when the surgeon is developing a treatment plan. For transverse femoral shaft fractures, the results of this study suggest that a working length of 2 screw holes on either side of the fracture may also lead to lower peak stress. In addition, our results demonstrate that minimizing the fracture gap and interface gap will lead to decreased stress in the plate-screw construct.

Effect comparison of knee-chest elastic bandage fixation and Pavlik harness fixation on the treatment of femoral shaft fractures in newborns

Objective:To study and analyze the clinical efficacy of fixation of the elastic bandage of immobilization of knee-chest position and Pavlik harness fixation in the treatment of neonatal femoral shaft fractures.Methods:A retrospective analysis was conducted from May 2010 to March 2017 with a total of 37 cases of femoral shaft fracture of the newborn.Among them,17 newborns with femur shaft fracture were treated using this fixation of the elastic bandage of immobilization of knee-chest position,and 20 newborns were treated utilizing Pavlik harness fixation.All patients were followed up for 24 months.It was compared between the two groups in length of hospitalization,hospitalization cost,the incidence of complications,fracture healing rate and post-operation angulation,rotation and shortening indexes.Results:Compared with the Pavlik harness fixation group,the hospitalization cost of knee-chest elastic bandage fixation group was lower(P<0.05),the difference was statistically significant.There is no significant difference between the two groups in terms of length of hospitalization,complications and fracture healing.The two groups of treatment methods compared in angle formation,rotation and shortness(P>0.05),with no statistical difference.Conclusions:Both knee-chest elastic bandage fixation and Pavlik harness fixation are effective methods for the treatment of neonatal femoral shaft fractures.But the former has lower cost and simpler operation,which is worthy of clinical application.

Titanium elastic nailing in diaphyseal femoral fractures of children below six years of age

AIM To report the clinical and radiographic results of titanium elastic nail(TEN) in diaphyseal femoral fractures of children below age of six years.METHODS A retrospective analysis of 27 diaphyseal femoral fractures in children younger than six years treated with TEN between 2005 and 2015 was conducted. Patients were immobilized in a cast for 5 wk and the nails were removed from 6 to 12 wk after surgery. Twenty-four cases were clinically and radiographically re-evaluated using the Flynn's scoring criteria, focusing on: Limb length discrepancy, rotational deformity, angulation, hip and knee range of motion(ROM), functional status, complications, and parent's satisfaction.RESULTS Sixteen males and eight females with a mean age of 3.2 years at the time of treatment were re-evaluated at an average follow-up of 58.9 mo. No cases of delayed union were observed. The mean limb lengthening was 0.3 cm. Four cases experienced limb lengthening greater than 1 cm and always minor than 2 cm. Twelve point five percent of the cases showed an angulation < 10°. Complete functional recovery(hip and knee ROM, ability to run and jump on the operated limb) occurred in 95.7% of cases. Complications included two cases of superficial infection of the TEN entry point, one case of refracture following a new trauma, and one TEN mobilization. According to the Flynn's scoring criteria, excellent results were obtained in 79.2% of patients and satisfactory results in the remaining 20.8%, with an average parent's satisfaction level of 9.1/10.CONCLUSION TEN is as a safe, mini-invasive and surgeon-friendly technique and, considering specific inclusion criteria, it represents a useful and efficacy option for the treatment of diaphyseal femoral fractures even in patients younger than six years of age.

Missed diagnosis of femoral deep artery rupture after femoral shaft fracture: A case report

BACKGROUND Vascular injury is a rare complication of femoral shaft fractures,and rupture of the deep femoral artery is more difficult to diagnose because of its anatomical location and symptoms.Despite its low incidence,deep femoral artery rupture can lead to life-threatening outcomes,such as compartment syndrome,making early identification and diagnosis critical.CASE SUMMARY A 45-year-old male patient was admitted to our hospital due to right lower limb trauma in a car accident,with complaints of severe pain and swelling on his right thigh.X-ray demonstrated a right femoral shaft fracture.During preparation for emergency surgery,his blood pressure and blood oxygen saturation dropped,and sensorimotor function was lost.Computed tomography angiography was performed immediately to confirm the diagnosis of rupture of the deep femoral artery and compartment syndrome,so fasciotomy and vacuum-assisted closure were performed.Rhabdomyolysis took place after the operation and the patient was treated with appropriate electrolyte correction and diuretic therapy.Twenty days after the fasciotomy,treatment with the Hoffman Type II External Fixation System was planned,but it was unable to be immobilized internally based on a new esophageal cancer diagnosis.We kept the external fixation for 1 year,and 3 years of follow-up showed improvement of the patient’s overall conditions and muscle strength.CONCLUSION For patients with thigh swelling,pain,anemia,and unstable vital signs,anterior femoral artery injury should be highly suspected.Once diagnosed,surgical treatment should be performed immediately and complications of artery rupture must be suspected and addressed in time.

Intramedullary bone pedestal formation contributing to femoral shaft fracture nonunion:A case report and review of the literature

BACKGROUND Femoral shaft fracture is a commonly encountered orthopedic injury that can be treated operatively with a low overall delayed/nonunion rate.In the case of delayed union after antegrade or retrograde intramedullary nail fixation,fracture dynamization is often attempted first.Nonunion after dynamization has been shown to occur due to infection and other aseptic etiologies.We present a unique case of diaphyseal femoral shaft fracture nonunion after dynamization due to intramedullary cortical bone pedestal formation at the distal tip of the nail.CASE SUMMARY A 37-year-old male experienced a high-energy trauma to his left thigh after coming down hard during a motocross jump.Evaluation was consistent with an isolated,closed,left mid-shaft femur fracture.He was initially managed with reamed antegrade intramedullary nail fixation but had continued thigh pain.Radiographs at four months demonstrated no evidence of fracture union and failure of the distal locking screw,and dynamization by distal locking screw removal was performed.The patient continued to have pain eight months after the initial procedure and 4 mo after dynamization with serial radiographs continuing to demonstrate no evidence of fracture healing.The decision was made to proceed with exchange nailing for aseptic fracture nonunion.During the exchange procedure,an obstruction was encountered at the distal tip of the failed nail and was confirmed on magnified fluoroscopy to be a pedestal of cortical bone in the canal.The obstruction required further distal reaming.A longer and larger diameter exchange nail was placed without difficulty and without a distal locking screw to allow for dynamization at the fracture site.Post-operative radiographs showed proper fracture and hardware alignment.There was subsequently radiographic evidence of callus formation at one year with subsequent fracture consolidation and resolution of thigh pain at eighteen months.CONCLUSION The risk of fracture nonunion caused by intramedullary bone pedestal formation can be mitigated with the use of maximum length and diameter nails and close follow up.

Bone metabolism and trauma degree of magnetic-guided intramedullary nail fixation for femoral shaft fracture

Objective:To explore the effect of magnetic-guided intramedullary nail fixation on bone metabolism and trauma degree in patients with femoral shaft fracture.Methods: A total of 128 patients with femoral shaft fractures who received surgical treatment in the hospital between April 2016 and November 2017 were divided into control group (n=64) and study group (n=64) according to the random number table method. Control group received the traditional intramedullary nail treatment, and study group received magnetic-guided intramedullary nail treatment. The differences in serum levels of bone metabolism indexes and inflammatory factors were compared between the two groups 48 h after surgery.Results: 48 h after surgery, serum bone formation indexes BGP, PⅠNP, PⅠCP and BAP levels of study group were higher than those of control group whereas bone resorption indexesβ-CTX, TRACP5b and NTX levels were lower than those of control group;serum inflammatory factors TGF-β, hs-CRP, IL-1β, IL-6 and IL-17 levels were lower than those of control group.Conclusion:Compared with traditional intramedullary nail therapy, magnetic-guided intramedullary nail fixation can more effectively balance the bone metabolism status and reduce the fracture end trauma in patients with femoral shaft fracture.

Trauma and bone metabolism of magnetic navigation intramedullary nail and traditional intramedullary nail fixation treatment of femoral shaft fracture

Objective:To analyze the trauma and bone metabolism of magnetic navigation intramedullary nail and traditional intramedullary nail fixation treatment of femoral shaft fracture. Methods:58 patients with femoral shaft fracture treated in our hospital between December 2011 and December 2015 were divided into observation group and control group by random number table (n=29). Control group received conventional intramedullary nail fixation treatment, and observation group received magnetic navigation intramedullary nail fixation treatment. 24 h after surgery, blood coagulation indexes, enzymology indexes, bone metabolism indexes and angiogenesis indexes were determined;6 months after surgery, bone mineral density levels were determined. Results:24 h after surgery, peripheral blood thrombin time (TT), prothrombin time (PT), and activated partial thromboplastin time (APTT) levels of observation group were significantly higher than those of control group, and serum fibrinogen (FIB), D-Dimer (D-D), lactate dehydrogenase (LDH), creatine kinase (CK), creatine kinase isoenzyme (CKMB), glutamic oxalacetic transaminase (GOT), sex hormone-binding globulin type I (SHBG), collagen cross-linked carboxyl-terminal telopeptide (CTX) and deoxypyridinoline (DPD) content were lower than those of control group while bone gla protein (BGP), insulin-like growth factor (IGF-1), hypoxia-inducible factor-1α (HIF-α), angiogenin 1 (Ang-1), recombinant basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) content were higher than those of control group;6 months after surgery, fracture end bone mineral density (BMD) value of observation group was higher than that of control group. Conclusions:Magnetic navigation intramedullary nail treatment of femoral shaft fracture can more effectively reduce the surgical trauma, improve bone metabolism and increase bone mineral density.

Treatment of long-segment fracture in middle-up part of femoral shaft with long proximal femoral nail anti-rotation of AO/ASIF

Objective To investigate the operative method and evaluate the clinical outcomes of long proximal femoral nail anti-rotation (PFNA-long) in treating long-segment fracture in middle-up part of femoral bone.Methods From June 2006 to

Comparison of three kinds of treatment for pediatric closed femoral shaft fracture

To compare and evaluate 3 kinds of treatments of pediatric closed femoral shaft fractures.Methods Seventy-nine patients were divided into 3 groups and treated using hip spica casting after skeletal traction,unilateral multifunctional fixation and plate fixation.The result were evaluated according to clinical function,time to union,complications,radiology examination and the economic cost.Results Both time to union and economic cost of the external fixation group were shorter than that of the skeletal traction group and plate fixation group.Conclusion The unilateral multi-functional external fixation is an ideal solution to pediatric close femoral shaft fractures.7 refs,3 tabs.

顺行和逆行髓内钉治疗不同部位股骨干骨折的有限元分析

背景:髓内钉治疗股骨干骨折取得了较好的临床疗效,但仍有部分患者并发无菌性骨不连,其原因为机械性不稳定。股骨作为人体最长最大的骨骼,不同部位骨折是否具有不同的生物力学特征,及不同进钉方式对于不同部位骨折端稳定性存在何种影响均研究甚少。目的:分析顺行和逆行髓内钉治疗不同部位股骨干骨折的生物力学特点,评估最佳进钉方式,减少骨不连发生率。方法:选取一名志愿者CT资料导入Mimics 19.0和Geomagic studio 2017软件中进行提取、优化得到右侧股骨三维模型;运用Solidworks 2017软件画出顺行和逆行髓内钉模型并与不同骨折部位股骨干骨折模型按照标准手术技术装配,以STEP格式导入Abaqus 2017软件中设置材料属性参数、边界条件、施加载荷、提交运算,于可视化模块中查看结果。其中上段股骨干骨折顺行和逆行髓内钉分别为A1、A2模型,中段为B1、B2模型,下段为C1、C2模型。结果与结论:(1)A1、B1、C2模型股骨整体应力分布更为均匀,位移、骨折端间隙与成角、股骨近折端骨块内翻均更小;(2)对于上段和中段股骨干骨折,顺行髓内钉具有更好的生物力学效果;对于下段股骨干骨折,逆行髓内钉效果更优。

数字断层融合摄影技术在股骨干骨折内固定术后的应用研究

目的探讨数字断层融合摄影(DTS)在股骨干骨折内固定术后复查中的应用价值。方法收集90例股骨干骨折内固定术后患者,于术后6月时完成了数字化X线摄影(DR)及DTS检查。由两名放射科医师采用5分法对两种影像学检查方法所获图像进行图像质量评价及对比。同时由临床医师对DTS及DR的骨折愈合显示率进行对比。结果术后6月时,DTS图像质量评分为(3.689±1.148)分,DR图像质量评分为(2.778±1.197)分,两组差异具有统计学意义(P<0.05)。DTS图像骨折愈合情况显示率为95.56%(86/90),DR图像骨折愈合情况显示率为72.23%(65/90),差异具有统计学意义(P<0.05)。结论在股骨干骨折内固定术后复查中,DTS能清晰显示术区骨质结构,准确判断骨折愈合情况,图像质量较DR更优,可作为股骨干骨折内固定术后复查较为理想的影像学检查方法,临床实用性较强。

加长型股骨近端防旋髓内钉治疗股骨干合并同侧股骨转子间骨折

目的探讨加长型股骨近端防旋髓内钉(PFNA)治疗股骨干合并同侧股骨转子间骨折的疗效。方法采用加长型PFNA治疗30例股骨干合并同侧股骨转子间骨折患者。记录骨折愈合情况、患者下地行走情况、髋及膝关节活动度、并发症发生情况。采用Sanders评分评价髋关节功能。结果患者均获得随访,时间12~40个月。术后1个月股骨转子间骨折线开始模糊,骨折愈合时间3~6个月;术后3个月股骨干骨折端周围均骨痂丰富,包裹断端,骨折愈合时间4~9个月。术后均未发生血管损伤、脂肪栓塞、下肢深静脉血栓、骨折再移位、内固定松动等并发症。末次随访时,髋关节屈曲110°~120°、后伸5°~10°,膝关节屈曲110°~115°、伸直0°。患者均可弃拐行走,其中24例步态正常,5例轻度跛行,1例跛行明显;采用Sanders评分评价髋关节功能:优24例,良5例,差1例,优良率29/30。结论加长型PFNA治疗股骨干合并同侧股骨转子间骨折创伤小,安全性高,患者功能恢复快,疗效满意。

辅助治疗股骨干骨折缺损数值模拟分析

针对股骨干断裂骨折患者手术治疗康复治疗问题,使用医学影像处理和逆向工程技术,依据股骨CT扫描数据,重构股骨干2mm横断缺损和股骨干10°楔形缺损断裂模型。为了分析接骨板、螺钉应力、应变变化规律及股骨整体应力集中状况,在700N轴向载荷和15N·m扭转载荷条件下,建立锁定型和锁定加压型接骨板数值模拟系统进行数值模拟分析。结果发现:锁定加压型内固定系统适用于股骨干2mm横断模型,螺钉不易发生失效断裂;锁定型内固定系统适用于股骨干10°楔形缺模型,螺钉未出现失效断裂现象,便于患者康复。

Treatment of pediatric femoral shaft fractures by stainless steel and titanium elastic nail system： A randomized comparative trial

Purpose： Literature suggests that the lower modulus of elasticity of titanium makes it ideal for use in children compared with stainless steel. Better fracture stability was observed in association with tita- nium nails on torsional and axial compression testing. However, stainless steel nails are stiffer than ti- tanium counterparts, which may provide a rigid construct when fixing paediatric femoral shaft fractures. Complications have been observed more frequently by various researchers when titanium nails are used for fracture fixation in patients with increasing age or weight. The concept of this study was to compare the functional outcome after internal fixation with titanium elastic nail system and stainless steel elastic nail system in paediatric femoral shaft fractures. Methods： The study was conducted on 34 patients admitted in the department of orthopaedics, LLRM Medical College ＆ SVBP Hospital, Meerut, India from January 2013 to August 2014. We included patients aged 5-12 years with fracture of the femoral shaft, excluding compound fractures, pathological fractures and other lower limb fractures. Patients were treated by titanium （n = 17） or stainless steel （n - 17） elastic nail system and followed up for one year. The clinical parameters like range of motion at hip and knee joints, time to full weight bearing on the operated limb and radiological parameters like time to union were compared between two groups. A special note was made of intra- and post-operative complications. Functional outcomes were analysed according to Flynn criteria. Results： Based on the Flynn criteria, 59% of patients had excellent results, 41% had satisfactory results, and no one showed poor results. There was no clinically significant difference between the two groups with respect to time to union and full weight bearing. But the incidence of puncture of the opposite cortex while inserting the nail and trying to advance it through the diaphysis during operation is greatly different. Only one such case was observed in titanium group but five in stainless steel group. Conclusion： Majority of paediatric femoral shaft fractures are now treated operatively by elastic stable intramedullary nails. Operative intervention results in a shorter hospital stay and has economic and social benefits over conservative treatment. The cost of stainless steel nail is one third the cost of tita- nium nail. However, the clinico-radiological results are not significantly different between titanium and stainless steel nails at one year follow-up as observed by our study.

1例儿童股骨干骨折术后残留畸形原因分析

股骨干骨折为临床中常见病、多发病,其治疗方法有保守治疗、手术治疗,治疗要求骨折断端坚强的固定,确保良好的对位对线,以达到骨折如期愈合,避免出现并发症。如果治疗方法、内固定物选择错误,就会出现骨折延迟愈合、不愈合甚至残留畸形,给患者及家庭带来灾难。本文通过股骨干骨折患儿历经6次手术治疗,分析整个治疗过程,找到治疗过程中存在的失误及不足,总结失败的经验教训,为后期临床医生治疗儿童股骨干骨折敲响警钟。

Pediatric femoral shaft fractures treated by flexible intrameduUary nailing

Background： Nowadays pediatric femoral fractures are more commonly managed with operative treatment rather than conservative treatment because of more rapid recovery and avoidance of prolonged immobilization. Children between the ages of 5-13 years are treated either by traction plus hip spica and flexible/elastic stable retrograde intramedullary nail, or external fixators in the case of open fractures. The aim of this study is to evaluate the outcome of pediatric femoral shaft fractures treated by stainless steel flexible intramedullary nail in children between 5 and 13 years of age. Methods： There were 32 cases of femoral shaft fractures which were all fixed with stainless steel flexible intramedullary nail under fluoroscopy. Long leg cast was applied at the time of fixation. Partial weight bearing was started 2 weeks after surgery. Patients were evaluated in follow-up study to observe the alignment of fracture, infection, delayed union, nonunion, limb length discrepancy, motion of knee joint, and time to unite the fracture. Results： We were able to follow up 28 out of 32 patients. The patients were 8.14 years of age on average. The mean hospital stay after operation was 4 days and fracture union time was 9.57 weeks. There were 3 cases of varus angulation, 2 cases of anterior angulation, and 4 cases of limb lengthening. Conclusion： Patients aged between 5 and 13 years treated with flexible intramedullary nail for closed femoral shaft fracture have rapid union and recovery, short rehabilitation period, less immobilization and psychological impact, and cost-effective.

Ipsilateral proximal and shaft femoral fractures

Purpose： To study the management and evaluate anatomical and functional outcomes of patients with ipsilateral proximal and shaft femoral fractures. Methods： A retrospective, descriptive and analytic study lasted for ten years and a half ranging from January 1, 2005 to June 30, 2015. The following parameters were studied： epidemiology, fracture char- acteristics, therapeutic, anatomical and functional outcomes. The correlation between different param- eters was analyzed with Fischer test. The significant threshold was defined for p value 〈0.05. Results： Ten medical files were registered. There were 7 men and 3 women, with a sex ratio of 2.33. The average age was 46 years （range： 29-62 years）. It was about traffic road accidents in all cases. Motorcycle -motorcycle and motorcycle-car collision were most frequent. Average admission delay was 7 h （range： 1.5-24 h）. Left side was most reached in 8 cases. According to Garden classification, there was type Ⅲ cervical fracture in 2 cases, type Ⅱ in 1 case and type Ⅳ in 1 case. According to Ender classification, there was type I trochanteric fracture in 3 cases, type Ⅵ in 2 cases and type Ⅶ in 1 case. According to AO classification, there was type A shaft fracture in 6 cases （A2 in 4 cases and A3 in 2 cases）, type B in 2 cases （BI in 1 case and B2 in 1 case） and type C in 2 cases （CI in 1 case and C2 in 1 case）. Average surgical delay was 28.7 days （range： 11-61 days）. For proximal femoral fracture, Moore prosthesis was used in 1 case, blade plate 130° in 2 cases, long Gamma nail in 4 cases, double screwing in 2 cases and dynamic hip screw in 1 case. For shaft femoral fracture, blade plate 95° was used in 3 cases, low compressive plate in 2 cases. Osseous contention was achieved in 4 cases with long Gamma nail and in 1 case with long blade plate 130°. Nonunion of cervical fracture was achieved in 2 cases. The average osseous healing delay was 5.14 months （range： 3-12 months） for proximal femoral fracture and 5 months （range： 3-8 months） for shaft femoral fractures. According to Friedman and Wyman criteria, functional results were good in 4 cases, average in 4 cases and bad in 2 cases. Regarding implants, healing delay showed no statistic difference between one-implant group and two-implant group （p = 0.52）, and among the patients with different functional outcomes （p = 0.52）. Functional outcomes showed no statistic difference between one-implant group and two-implant group （p = 0.46）. Conclusion： Ipsilateral proximal and shaft femoral fractures are relatively uncommon in our daily ac- tivities. It is difficult to recognize proximal femoral fractures which are unnoticed. Results are generally good if the doctors take the two fractures into account in the management.