Ilizarov外固定架治疗儿童胫骨骨折的临床研究
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摘要
背景:儿童胫骨折是临床中最常见的骨折之一,传统治疗有石膏固定、下肢牵引、手术切开复位内固定等方法,每一种方法有其优缺点以及其限制因素。随着材料更新,生活节奏加快等因素,儿童胫骨骨折治疗亦出现改进。尽可能闭合复位Ilizarov外固定架固定治疗儿童胫骨骨折,具有微创、负重早、不受季节气温等因素影响。Ilizarov外固定架是一种三维立体结构外固定器,固定可靠,既可消除剪力和旋转应力,同时能发挥其单纯牵张应力或加压的作用,又能发挥在负重行走时的周期性轴向微动特点,该方法作为一种新兴的技术,符合儿童骨折的治疗原则,值得我们研究。
目的:总结和探讨Ilizarov技术治疗儿童胫骨骨折的适应症、手术技巧、临床疗效、并发症及注意事项。
方法:苏州大学附属儿童医院骨科2006年01月～2010年08月采用Ilizarov外固定架治疗儿童胫骨骨折共92例(肢),其中男58例,女34例;右侧54例,左侧38例;胫骨骨干近端1/3骨折26例,中段1/3骨折29例,远端1/3骨折37例。胫骨骨折按照AO分型:42-A1型13例,42-A2型31例,42-A3型21例,42-B2型17例,42-C3型10例。闭合性胫骨骨折74例,开放性骨折18例,开放性骨折按照Gustilo分类:Ⅰ型:7例。Ⅱ型:6例,Ⅲa型:3例,Ⅲb型:2例。受伤年龄3岁7个月～12岁,平均7.2岁;受伤至手术时间3小时～6天,平均2.7天。根据年龄、骨折类型和部位的不同,用不同型号的Ilizarov外固定架固定,愈合效果与其它治疗组(47例使用钢板固定,81例采用弹性髓内钉固定)进行统计学比较。
结果: 92例均获得随访,平均随访21个月。骨折愈合按照Johner-Wruh胫骨骨折愈合评定标准进行评估:优73例,(肢体不等长<1.0cm,骨折成角<5°,无疼痛,无关节活动受限,无跛行);良15例,(肢体不等长<2.0cm,骨折成角<10°,无疼痛,关节活动度>80﹪,偶尔跛行);中4例,(肢体不等长2～3cm,20°>骨折成角>10°,轻度疼痛,关节活动度>75﹪,轻微跛行),差0例。所有患儿骨折均愈合,骨折优良愈合率95.65﹪。无畸形愈合、无骨不连、无一例出现下肢Volkmann挛缩。2例系患肢不等长>2cm,随访1.5年,肢体不等长<1.0cm,无肢体短缩,1例踝关节活动度47﹪,1例膝关节活动度70﹪,功能练习半年后,踝关节活动度70﹪、膝关节活动度90﹪,优良率97.82﹪。本组无克氏针断裂和骨不连病例发生,无严重针道感染,开放性骨折中2例延迟愈合,骨折愈合时间为5～10周,平均8周。
结论: Ilizarov外固定架治疗儿童胫骨骨折,微创、固定稳固、可尽早恢复功能活动、愈合快、并发症少、固定架拔除方便、患儿易耐受。它适合所有胫骨骨折,尤其是开放性骨折和胫骨下段骨折。
Background: The tibial fractures is one of the most common fractures in children, The orthodox therapy include fixation by plaster,traction,operation and so on, there were multiform forte, demerit and a lot of limiting facts in every therapy. With the updated material, accelerating the space of life and so on,treatment of tibial fractures of children also progress. That as much as possible closed reduction and treatment of tibial fracture in children with Ilizarov fixator is minimally invasive, early weight-bearing, free from seasonal temperature and other factors. Ilizarov fixation is a three-dimentional structure of the external fixator and firmly fixed, while its alone distraction can play the role of stress or pressure,and it can play in weight-bearing walking cycle of axial micro features. To study on operation and curation and curative effects of surgical treatment of the tibial fracture in children with Ilizarov fixation was worthy to do.
Objective: To summarize indications, operation technique, clinical curative effect, complications, and precautions of the treatment of tibial fractures of children by Ilizarov fixation, and to provide a suit of methods to cure these fractures.
Methods:In the Children Hospital Affiliated to Soochow University, we collected 92 children who had been treated with Ilizarov fixation from January 2006 to August 2010, including 58 cases of male and 34 cases of female; 54 cases of right tibial fracture, 38 cases of left; 26 cases of proximal 1/3 tibial fracture, 29 cases of middle 1/3 the tibial fracture, 37 cases of distal 1/3 tibial fracture. Tibial fracture classification according AO: 13 cases of 42-A1 type, 31 cases of 42-A2 type, 21 cases of 42-A3 type, 17 cases of 42-B2 type, 10 cases of 42-C3 type; 74 cases of closed fracture, 18 cases of open fracture; Open fracture classification according Gustilo: 7 cases ofⅠtype, 6 cases ofⅡtype, 3 cases ofⅢa type, 2 cases ofⅢb type. Mean age of all patients was 7.2yr(range 3yr and 7mon～ 12yr).The average time from injury to operation is 2.7 days(range 3h～10ds). And according to different of the age,classification of fracture and site of the fracture, all fractures fixed with Ilizarov fixation,and comepared statistically the treatment result of intramedullary nail(81 cases) and plate fixation(47 cases) in tibial fracture of children.
Results: All of the 92 cases were followed up, and the mean follow-up was 21 months. According to the Johner-Wruh’s score standard, the excellent result (leg length inequality﹤1.0cm,malalignment﹤5°, no pain, no joint activity limitation, no limp,) were found in 73 cases; satisfactory result(leg length inequality﹤2.0cm,malalignment﹤10°, no pain, joint range of motion>80﹪, occasionally limp)in 15 cases; and middle result(leg length inequality 2～3cm, 20°>malalignment﹥10°, mild pain, joint range of motion>75﹪, slight limp)in 4 cases. poor result in 0 case. The excellent and good rates was 95.65﹪. All fractures healed in children, no nonunion, no Volkmann ischemic contracture, 2 cases belong to affected extremity be long>2.0cm, following up 1.5 year, leg length inequality<1.0cm. one case was ankle range of motion 47﹪, one case was knee range of motion 70﹪, and 2 cases recovered by exercise in half year, one case was ankle range of motion 70﹪, one case was knee range of motion 90﹪, one cases was still middle. The excellent and good rates was 97.82﹪. No broken and ununited cases,no pin tract infection in this team. 2 cases of all delayed union in open fracture.All the 92 patients were cured, and the time of bone healing was 5 to 10 weeks, 8 weeks on average.
Conclusions: The treatment of tibial fracture in children with Ilizarov fixator has many forte, such as small hurting, fixation, fast healing, earlier exercise, and rare complication, short period in hospital, convenience to pull out fixator and easy tolerance. It′s suitable for all tibial fractures, especially open fractures and distal fractures.
目的:总结和探讨Ilizarov技术治疗儿童胫骨骨折的适应症、手术技巧、临床疗效、并发症及注意事项。
方法:苏州大学附属儿童医院骨科2006年01月～2010年08月采用Ilizarov外固定架治疗儿童胫骨骨折共92例(肢),其中男58例,女34例;右侧54例,左侧38例;胫骨骨干近端1/3骨折26例,中段1/3骨折29例,远端1/3骨折37例。胫骨骨折按照AO分型:42-A1型13例,42-A2型31例,42-A3型21例,42-B2型17例,42-C3型10例。闭合性胫骨骨折74例,开放性骨折18例,开放性骨折按照Gustilo分类:Ⅰ型:7例。Ⅱ型:6例,Ⅲa型:3例,Ⅲb型:2例。受伤年龄3岁7个月～12岁,平均7.2岁;受伤至手术时间3小时～6天,平均2.7天。根据年龄、骨折类型和部位的不同,用不同型号的Ilizarov外固定架固定,愈合效果与其它治疗组(47例使用钢板固定,81例采用弹性髓内钉固定)进行统计学比较。
结果: 92例均获得随访,平均随访21个月。骨折愈合按照Johner-Wruh胫骨骨折愈合评定标准进行评估:优73例,(肢体不等长<1.0cm,骨折成角<5°,无疼痛,无关节活动受限,无跛行);良15例,(肢体不等长<2.0cm,骨折成角<10°,无疼痛,关节活动度>80﹪,偶尔跛行);中4例,(肢体不等长2～3cm,20°>骨折成角>10°,轻度疼痛,关节活动度>75﹪,轻微跛行),差0例。所有患儿骨折均愈合,骨折优良愈合率95.65﹪。无畸形愈合、无骨不连、无一例出现下肢Volkmann挛缩。2例系患肢不等长>2cm,随访1.5年,肢体不等长<1.0cm,无肢体短缩,1例踝关节活动度47﹪,1例膝关节活动度70﹪,功能练习半年后,踝关节活动度70﹪、膝关节活动度90﹪,优良率97.82﹪。本组无克氏针断裂和骨不连病例发生,无严重针道感染,开放性骨折中2例延迟愈合,骨折愈合时间为5～10周,平均8周。
结论: Ilizarov外固定架治疗儿童胫骨骨折,微创、固定稳固、可尽早恢复功能活动、愈合快、并发症少、固定架拔除方便、患儿易耐受。它适合所有胫骨骨折,尤其是开放性骨折和胫骨下段骨折。
Background: The tibial fractures is one of the most common fractures in children, The orthodox therapy include fixation by plaster,traction,operation and so on, there were multiform forte, demerit and a lot of limiting facts in every therapy. With the updated material, accelerating the space of life and so on,treatment of tibial fractures of children also progress. That as much as possible closed reduction and treatment of tibial fracture in children with Ilizarov fixator is minimally invasive, early weight-bearing, free from seasonal temperature and other factors. Ilizarov fixation is a three-dimentional structure of the external fixator and firmly fixed, while its alone distraction can play the role of stress or pressure,and it can play in weight-bearing walking cycle of axial micro features. To study on operation and curation and curative effects of surgical treatment of the tibial fracture in children with Ilizarov fixation was worthy to do.
Objective: To summarize indications, operation technique, clinical curative effect, complications, and precautions of the treatment of tibial fractures of children by Ilizarov fixation, and to provide a suit of methods to cure these fractures.
Methods:In the Children Hospital Affiliated to Soochow University, we collected 92 children who had been treated with Ilizarov fixation from January 2006 to August 2010, including 58 cases of male and 34 cases of female; 54 cases of right tibial fracture, 38 cases of left; 26 cases of proximal 1/3 tibial fracture, 29 cases of middle 1/3 the tibial fracture, 37 cases of distal 1/3 tibial fracture. Tibial fracture classification according AO: 13 cases of 42-A1 type, 31 cases of 42-A2 type, 21 cases of 42-A3 type, 17 cases of 42-B2 type, 10 cases of 42-C3 type; 74 cases of closed fracture, 18 cases of open fracture; Open fracture classification according Gustilo: 7 cases ofⅠtype, 6 cases ofⅡtype, 3 cases ofⅢa type, 2 cases ofⅢb type. Mean age of all patients was 7.2yr(range 3yr and 7mon～ 12yr).The average time from injury to operation is 2.7 days(range 3h～10ds). And according to different of the age,classification of fracture and site of the fracture, all fractures fixed with Ilizarov fixation,and comepared statistically the treatment result of intramedullary nail(81 cases) and plate fixation(47 cases) in tibial fracture of children.
Results: All of the 92 cases were followed up, and the mean follow-up was 21 months. According to the Johner-Wruh’s score standard, the excellent result (leg length inequality﹤1.0cm,malalignment﹤5°, no pain, no joint activity limitation, no limp,) were found in 73 cases; satisfactory result(leg length inequality﹤2.0cm,malalignment﹤10°, no pain, joint range of motion>80﹪, occasionally limp)in 15 cases; and middle result(leg length inequality 2～3cm, 20°>malalignment﹥10°, mild pain, joint range of motion>75﹪, slight limp)in 4 cases. poor result in 0 case. The excellent and good rates was 95.65﹪. All fractures healed in children, no nonunion, no Volkmann ischemic contracture, 2 cases belong to affected extremity be long>2.0cm, following up 1.5 year, leg length inequality<1.0cm. one case was ankle range of motion 47﹪, one case was knee range of motion 70﹪, and 2 cases recovered by exercise in half year, one case was ankle range of motion 70﹪, one case was knee range of motion 90﹪, one cases was still middle. The excellent and good rates was 97.82﹪. No broken and ununited cases,no pin tract infection in this team. 2 cases of all delayed union in open fracture.All the 92 patients were cured, and the time of bone healing was 5 to 10 weeks, 8 weeks on average.
Conclusions: The treatment of tibial fracture in children with Ilizarov fixator has many forte, such as small hurting, fixation, fast healing, earlier exercise, and rare complication, short period in hospital, convenience to pull out fixator and easy tolerance. It′s suitable for all tibial fractures, especially open fractures and distal fractures.
引文
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[51] Gopal S, Majumder S, Batchelor AGB, et al. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br. 2000;82(7):959-966.
[52] Lowenberg DW, Feibel RJ, Louie KW, et al. Combined muscle flap and Ilizarov reconstruction for bone and soft tissue defect. Clin Orthop. 1996;332:37-51.
[53] Yokoyama K, Itoman M, Nakamura K, et al. Free vascularized fibular graft vs Ilizarov method for posttraumatic tibial bone defect. J Reconstr Microsurgery. 2001;17(1): 17-25.
[54] Anglen JO. Early outcome of hybrid external fixation for fractures of the distal tibia. J Orthop Trauma. 1999;13(2):92-97.
[55] Paley D. Problems, obstacles and complications of limb lengthening by the llizarov technique. Clin Orthop Relat Res. 1990;(250):81-104.
[56] Rozbruch R, Helfet D, Blyakher A. Distraction of hypertrophic nonunion of tibia with deformity using Ilizarov/Taylor spatial frame. Arch Orthop Trauma Surg. 2002; 122(5):295-298.
[57] Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. J Bone Joint Surg. 2000;82-A(12):1681-1691.
[58] Kristiansen L, Steen H. No difference in tibial lengthening index by use of Taylor Spatial Frame or Ilizarov external fixator. Acta Orthop. 2006;77(5):772-777.
[59] Nowotarski PJ, Turen CH, Brumback RJ, et al.Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am. 2000;82(6): 781-788.
[60] Bonnevialle P, Mansat P, Cariven P, et al. Single-plane external fixation of fresh fractures of the femur: critical analysis of 53 cases. Rev Chir Orthop Reparatrice Appar Mot. 2005;91(5):446-456.
[1] Dennis R, wenger Maya E. pring. Rang小儿骨折第三版.北京:人民卫生出版社,2006:166.
[2] Thomas P, Ruedi,William M, Murphy,主编.王满宜等译.骨折治疗的AO原则.北京:华夏出版社,2003:675.
[3] Ballock RT, O′Keefe RJ. The biology of the growth plate. J Bone Joint Surg Am 2003;85-A(4):715-26.
[4]王海洲,许树柴,刘军,等.保守治疗儿童尺桡骨双骨折体会.中国中医骨伤科杂志. 2008;16(6):63.
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[6] Lee YH, Lim KB, Gao GX, et al. Traction and spica casting for closed femoral shaft fractures in children. J Orthop Surg. 2007;15(1):37-40.
[7]陆裕朴,胥少汀.实用骨科学.北京:人民军医出版社,1991:226.
[8] Lever JP, Aksenov SA, Zdero R, et al. Biomechanical analysis of plate osteosynthesis systems for proximal humerus fractures.J Orthop Trauma. 2008;22(1):23-29.
[9] Ramseier LE, Bhaskar AR, Cole WG, et al. Treatment of open femur fractures in children: comparison between external fixator and in-Tramedullyary nail. J Pediatr Orthop. 2007;27(7):748-50.
[10]荣国威,王承武.骨折.北京:人民卫生出版社,2004,1:625.
[11] Pape HC, Hildebrand F, Pertschy S, et al. Changes in the management of femoral shaft fractures in polytrauma patients:from early total care to damage control orthopedic surgery. J Trauma. 2002;53(3):452-461; discussion 461-462.
[12] Bennek J, Buhligen U, Rothe K, et al. Fracture treatment in children-data analysis and follow-up results of a prospective study. Injury. 2001;32(4): 26-29.
[13] Jones BG, Duncan RD. Open tibial fractures in children under 13 years of age-10 years experience. Injury. 2003;34(10):776-780.
[14] Myers SH, Spiegel D, Flynn JM. External fixation of high-energy tibia fractures. J Pediatr Orthop. 2007;27(5):537-539.
[15] Gordon JE, Schoenecker PL, Odaa JE, et al. A comparison of monolateral and circularexternal fixation of unstable diaphyseal tibial fractures in children. J Pedia Orthop B. 2003;12(5):338 -345.
[16] Catagni MA, Ottaviani G, Combi A, et al. External circular fixation: A comparison of infection rates between wires and conical half-pins with threads out side or inside the skin. J Trauma, 2006;61(5):1185-1191.
[17] Pankovich AM. Flexible intramedullary nailing of femoral shaft fracture. Instr Cours Lect. 1987;36:324-338.
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[22] Till H, Hüttl B, Knorr P, et al. Elastic stable intramedullary nailing(ESIN) provides good long-term results in pediatric long-bone fractures. Eur J Pediatr Surg. 2000 Oct;10(5):319-322.
[23] Ho CA, Skaggs DL, Tang CW, et al. Use of flexible intramedullary nails in pediatric femur fractures. J Pediatr Orthop. 2006;26(4):497-504.
[24] Vallamshetla VR, Desilva U, Bache CE, et al. Flexible intramedullary nails for unstable fractures of the tibia in children. An eight-year experience. J Bone Joint Surg Br. 2006;88(4):536-540.
[25] Kanlic E, Cruz M. Current concepts in pediatric femur fracture treatment. Orthop edics. 2007;30(12):1015-1059.
[26] Aksoy MC, Caglar O,Ayvaz M, et al. Treatment of complicated pediatric femoral fractures with titanium elastic nail. J Pediatr Orthop B. 2008;17(1):7-10.
[27] Kuremsky MA, Frick SL. Advances in the surgical management of pediatric femoral shaft fractures. Currop in Pediatr. 2007;19(1):51-57.
[28] Lascombes P, Haumont T, Joumeau P. Use and abuse of flexible intramedullarynailing in children and adolescents. J Pediatr Orthop. 2006;26(6):827-834.
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[51] Gopal S, Majumder S, Batchelor AGB, et al. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br. 2000;82(7):959-966.
[52] Lowenberg DW, Feibel RJ, Louie KW, et al. Combined muscle flap and Ilizarov reconstruction for bone and soft tissue defect. Clin Orthop. 1996;332:37-51.
[53] Yokoyama K, Itoman M, Nakamura K, et al. Free vascularized fibular graft vs Ilizarov method for posttraumatic tibial bone defect. J Reconstr Microsurgery. 2001;17(1): 17-25.
[54] Anglen JO. Early outcome of hybrid external fixation for fractures of the distal tibia. J Orthop Trauma. 1999;13(2):92-97.
[55] Paley D. Problems, obstacles and complications of limb lengthening by the llizarov technique. Clin Orthop Relat Res. 1990;(250):81-104.
[56] Rozbruch R, Helfet D, Blyakher A. Distraction of hypertrophic nonunion of tibia with deformity using Ilizarov/Taylor spatial frame. Arch Orthop Trauma Surg. 2002; 122(5):295-298.
[57] Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. J Bone Joint Surg. 2000;82-A(12):1681-1691.
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[59] Nowotarski PJ, Turen CH, Brumback RJ, et al.Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am. 2000;82(6): 781-788.
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[1] Dennis R, wenger Maya E. pring. Rang小儿骨折第三版.北京:人民卫生出版社,2006:166.
[2] Thomas P, Ruedi,William M, Murphy,主编.王满宜等译.骨折治疗的AO原则.北京:华夏出版社,2003:675.
[3] Ballock RT, O′Keefe RJ. The biology of the growth plate. J Bone Joint Surg Am 2003;85-A(4):715-26.
[4]王海洲,许树柴,刘军,等.保守治疗儿童尺桡骨双骨折体会.中国中医骨伤科杂志. 2008;16(6):63.
[5] Dwyer AJ, John B, Mam MK, et al. Remodeling of tibial fractures in children younger than 12 years. Orthop aedics. 2007;30(5):393-396.
[6] Lee YH, Lim KB, Gao GX, et al. Traction and spica casting for closed femoral shaft fractures in children. J Orthop Surg. 2007;15(1):37-40.
[7]陆裕朴,胥少汀.实用骨科学.北京:人民军医出版社,1991:226.
[8] Lever JP, Aksenov SA, Zdero R, et al. Biomechanical analysis of plate osteosynthesis systems for proximal humerus fractures.J Orthop Trauma. 2008;22(1):23-29.
[9] Ramseier LE, Bhaskar AR, Cole WG, et al. Treatment of open femur fractures in children: comparison between external fixator and in-Tramedullyary nail. J Pediatr Orthop. 2007;27(7):748-50.
[10]荣国威,王承武.骨折.北京:人民卫生出版社,2004,1:625.
[11] Pape HC, Hildebrand F, Pertschy S, et al. Changes in the management of femoral shaft fractures in polytrauma patients:from early total care to damage control orthopedic surgery. J Trauma. 2002;53(3):452-461; discussion 461-462.
[12] Bennek J, Buhligen U, Rothe K, et al. Fracture treatment in children-data analysis and follow-up results of a prospective study. Injury. 2001;32(4): 26-29.
[13] Jones BG, Duncan RD. Open tibial fractures in children under 13 years of age-10 years experience. Injury. 2003;34(10):776-780.
[14] Myers SH, Spiegel D, Flynn JM. External fixation of high-energy tibia fractures. J Pediatr Orthop. 2007;27(5):537-539.
[15] Gordon JE, Schoenecker PL, Odaa JE, et al. A comparison of monolateral and circularexternal fixation of unstable diaphyseal tibial fractures in children. J Pedia Orthop B. 2003;12(5):338 -345.
[16] Catagni MA, Ottaviani G, Combi A, et al. External circular fixation: A comparison of infection rates between wires and conical half-pins with threads out side or inside the skin. J Trauma, 2006;61(5):1185-1191.
[17] Pankovich AM. Flexible intramedullary nailing of femoral shaft fracture. Instr Cours Lect. 1987;36:324-338.
[18] Flynn JM, Hresko T, Reynolds RA, et al. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop. 2001;21(1):4-8.
[19] Michael A. Medullry naillng for fracture of the shaft of the tibia. J Bone Joint Surg(Br). 1992;44-B:328.
[20] Kubiak EN, Egol KA, Scher D, et al. Operative treatment of tibial fractures in children: are elastic stable intramedullary nails an improvement over external fixation. J Bone Joint Surg (Am). 2005;87(8):1761-1768.
[21] Salem KH, Lindemann I, Keppler P. Flexible intramedullary nailing in pediatric lower limb fractures. J Pediatr Orthop. 2006;26(4):505-509.
[22] Till H, Hüttl B, Knorr P, et al. Elastic stable intramedullary nailing(ESIN) provides good long-term results in pediatric long-bone fractures. Eur J Pediatr Surg. 2000 Oct;10(5):319-322.
[23] Ho CA, Skaggs DL, Tang CW, et al. Use of flexible intramedullary nails in pediatric femur fractures. J Pediatr Orthop. 2006;26(4):497-504.
[24] Vallamshetla VR, Desilva U, Bache CE, et al. Flexible intramedullary nails for unstable fractures of the tibia in children. An eight-year experience. J Bone Joint Surg Br. 2006;88(4):536-540.
[25] Kanlic E, Cruz M. Current concepts in pediatric femur fracture treatment. Orthop edics. 2007;30(12):1015-1059.
[26] Aksoy MC, Caglar O,Ayvaz M, et al. Treatment of complicated pediatric femoral fractures with titanium elastic nail. J Pediatr Orthop B. 2008;17(1):7-10.
[27] Kuremsky MA, Frick SL. Advances in the surgical management of pediatric femoral shaft fractures. Currop in Pediatr. 2007;19(1):51-57.
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