Delayed Bone Healing in Pediatric Fractures: Key Concerns

Bone healing in the absence of a fracture gap?

A 3-month-old child was involved in a car accident and has now been followed up for four months without any signs of bone healing.
The surgeon has not provided any information or discussion, only advising us to be patient.
I have several concerns to address:
1.
The child has a closed comminuted fracture of the femur, with surgical intervention involving the placement of a steel plate and screws.
There are two large triangular fragments of bone.
Why were these fragments not repositioned to their original location?
2.
The X-rays show a significant gap in the fractured bone, and on the other side, there is a defect where bone is missing.
Why has there been no bone proliferation after four months?
3.
Is bone grafting effective for this type of non-union? Should we disregard the fragments of bone that remain in the femur?
My ability to express these concerns in professional terminology is limited.
I have attached two X-ray images for reference.
Please clarify my doubts and suggest the appropriate treatment direction.
Thank you.

Lao Die, 10~19 year old female. Ask Date: 2016/07/19

Dr. Shi Guozheng reply Orthopedics

1.
The physician used an intramedullary nail fixation method (closed nailing, fixed with interlocking nail) for the fracture without opening the site, which is the best approach.
This method preserves local blood circulation, facilitating easier healing of the fracture, thus there is no need for reoperation.

2.
A comminuted femoral fracture typically takes six to twelve months to heal, and in some cases, it may take up to eighteen months.

3.
If healing does not occur after one year, autogenous bone grafting should be considered instead of using bone graft substitutes, as nonunion may sometimes be related to the severity of the initial injury.

4.
The surgery appears to have been performed very well based on the X-ray images.

Reply Date: 2016/07/19

More Info

Understanding delayed bone healing in pediatric fractures can be quite complex, especially in cases involving significant injuries such as a closed comminuted fracture of the femur. In your situation, where four months have passed without evidence of healing, it is essential to address several key concerns regarding the healing process, treatment options, and the implications of the current condition.

1. Why were the bone fragments not repositioned?
In cases of comminuted fractures, especially those involving multiple fragments, the surgical approach may vary. The decision not to reposition the fragments could be based on several factors, including the stability of the fracture, the potential for vascular supply to the fragments, and the overall alignment of the limb. Surgeons often prioritize maintaining the overall alignment and stability of the limb rather than attempting to reposition every fragment, particularly if they believe that the surrounding soft tissue and bone healing will suffice to support recovery.

2. Significant gaps in the fracture site:
The presence of a large gap between the fractured bone ends can indeed complicate healing. In pediatric patients, the healing process is generally more robust due to the presence of growth plates and the remodeling potential of young bones. However, if there is a significant gap, it may hinder the natural healing process. The body relies on the formation of a callus (a new bone formation) to bridge the gap, and if this is not occurring, it may indicate a need for further intervention.

3. Effectiveness of bone grafting materials:
Bone grafting materials, such as bone powder or grafts from other parts of the body, can be effective in stimulating healing in cases where there is a gap or non-union. These materials provide a scaffold for new bone growth and can enhance the healing process by promoting osteogenesis (the formation of new bone). However, the effectiveness can vary based on the individual case, the type of graft used, and the overall health of the patient.

4. Management of residual fragments:
Regarding the fragments that remain in the leg, the approach can depend on their size, location, and whether they are causing any symptoms or complications. In some cases, small fragments may be left alone if they are not causing issues, as the body can often encapsulate them over time. However, if there is concern about infection, pain, or other complications, surgical intervention may be necessary to remove them.

5. Next steps and treatment direction:
Given the current situation, it is crucial to have a thorough discussion with your orthopedic surgeon. You should express your concerns regarding the lack of healing and the presence of gaps in the fracture site. It may be beneficial to seek a second opinion from another orthopedic specialist, particularly one with experience in pediatric fractures. They may recommend further imaging studies, such as a CT scan, to assess the fracture healing more accurately and determine the best course of action, which could include additional surgical intervention, the use of bone grafts, or other therapies.

In summary, while pediatric bones have a remarkable ability to heal, certain factors can impede this process. It is essential to maintain open communication with your healthcare provider, advocate for your child's needs, and explore all available treatment options to ensure the best possible outcome.

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