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Original: M.L. Routt, Jr., M.D. Revised October, 2011: Andrew R. Evans, M.D.
Treatment Options
Traction Spica Casting Pins & Plaster External Fixation Internal Fixation Plate/Screws Flexible nails Rigid Intramedullary rods - trochanteric vs. lateral entry
<2cm shortening
Enhanced ease of care Shorter hospital stay No defined optimal weight range Spica casting in ED versus OR yield similar reduction quality and complication rates
Traction with delayed spica casting Skin traction typically ineffective; skeletal traction often required
Spica casting
Insufficient evidence to recommend for/against (AAOS Clinical PracticeGuideline) Mode of treatment may be altered if deemed necessary
External fixation
Rigid intramedullary nailing - greater trochanteric entry femoral nail Well suited for unstable fracture patterns Patients >108lbs (49kg) who are not candidates for flexible IM nailing Piriformis or near-piriformis entry nailing is NOT a treatment option Risk of injury to the lateral ascending cervical branches of the medial femoral circumflex vessel in the piriformis fossa Increased risk of femoral head osteonecrosis (4%) Risk of coxa vara due to trochanteric apophyseal growth arrest Permits rapid mobilization
References
Aksahin E, et. al. Immediate Incorporated Hip Spica Casting in Pediatric Femoral Fractures: Comparison of Efficacy Between Normal and High Risk Groups. Journal of Pediatric Orthopaedics 2009; 29(1): 39-43. Anglen JO, Choi L. Treatment Options in Pediatric Femoral Shaft Fractures. Journal of Orthopaedic Trauma 2005; 19(10): 724-733. Flynn HM, Luedtke LM, Ganley TJ, Dawson J, Davidson RS, Dormans JP, Ecker ML, Gregg JR, Horn BD, Drummond DS. Comparison of Titanium Elastic Nails With Traction and a Spica Cast to Treat Femoral Fractures in Children. J Bone & Joint Surg Am 2004; 86: 770-777. Flynn JM, Schwend RM. Management of Pediatric Femoral Fractures. JAAOS 2004; 12(5): 347-359. Garner MR, Bhat SB, Khujanazarov I, Flynn JM, Spiegel D. Fixation of Length-Stable Femoral Shaft Fractures in Heavier Children. Journal of Pediatric Orthopaedics 2011; 31(1): 11-16. Gautier E, Ganz K, Krugel N, Gill T, Ganz R. Anatomy of the Medial Femoral Circumflex Artery and Its Surgical Implications. J Bone & Joint Surg Br 2000; 82(5): 679-683. Hosalkar HS, Pandya NK, Cho RH, Glaser DA, Moor MA, Herman MJ. Intramedullary Nailing of Pediatric Femoral Shaft Fractures. JAAOS 2011; 19(8): 472-481. Mansour AA, Wilmoth JC, Mansour AS, Lovejoy SA, Mencio GA, Martus JE. Immediate Spica Casting of Pediatric Femoral Fractures in the Operating Room Versus the Emergency Department: Comparison of Reduction, Complications, and Hospital Charges. Journal of Pediatric Orthopaedics 2010; 30(8): 813-817. Kocher MS, Sink EL, Blasier RD, Luhmann SJ, Mehlman CT, Scher DM, Matheney T, Sanders JO, Watters WC, Goldberg MJ, Keith MW, Haralson RH, Turkelson CM, Wies JL, Sluka P, Hitchcock K. AAOS Clinical Practice Guideline Summary: Treatment of Pediatric Diaphyseal Femur Fractures. JAAOS 2009; 17: 718-725. Poolman RW, Kocher MS, Bhandari M. Pediatric Femoral Fractures: A Systematic Review of 2422 Cases. Journal of Orthopaedic Trauma 2006; 20(9): 648-654. Sagan ML, Datta JC, Olney BW, Lansford TJ, McIff TE. Residual Deformity After Treatment of Pediatric Femur Fractures With Flexible Titanium Nails. Journal of Pediatric Orthopaedics 2010; 30(7): 638-643.
References
Sink EL, Faro F, Polousky J, Flynn K, Gralla J. Decreased Complications of Pediatric Femur Fractures With a Change in Management. Journal of Pediatric Orthopaedics 2010; 30(7): 633-637. Wright JG. The Treatment of Femoral Shaft Fractures in Children: A Systematic Overview and Critical Appraisal of the Literature. Canadian Journal of Surgery 2000; 43(3): 180-189.
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