Pediatric Femoral Shaft

Fractures

Dr. Tahir Mahmood

Lahore General Hospital
Lahore
Pediatric Femur Fractures
 1.6 % of all children Fractures
 28/100,000 child per year
 3:1 Male / Female ratio
 Children >3 yrs- highest incidence
 Seasonal- highest summer
 Anatomy and Growth
 Proximal femoral
physis- 30% of
longitudinal growth
 Distal femoral physis-
70% of longitudinal
growth
 Rapid increase in
cortical thickness
 Pediatric Femur Fractures-
Mechanism of Injury
 Rule out child abuse
 Falls- young children/toddlers
 Struck by vehicle- juvenile
 Recreational sports/activities- adolescent
 Motor vehicle crashes- all age groups
 Mechanism of Injury
 Low Energy
 High Energy

* predicts
behavior/treatment of
the fracture
 Pediatric Femur Fractures-
Associated Injuries
 Struck by car- triad of femur fracture, torso
injuries, head injury
 Potential damage to physis of femur and
proximal tibia
 Head Injury – spasticity can make traction and
cast treatment difficult
 Abdominal injury – spica cast can constrict
abdomen and limit ability to examine
Spasticity Leading to Extreme
Angulation and Shortening
 Physical Exam
 Complete exam: head, chest, abdomen, and
other skeletal segments
 Document distal neurological and vascular
function
 Palpate all bones
 First Aid principles - Splint or traction,
especially prior to transfer to another
institution
 Radiographic Evaluation
 AP Pelvis
 AP/Lat femur
 Visualize hip & knee
joints
 Classification

 Fracture pattern
 transverse, spiral, oblique, comminuted, greenstick
 Amount of shortening
 Angular deformity
 Open / closed
 7 Principles
Dameron & Thompson
 1. Simplest treatment best
 2. Initial treatment permanent when possible
 3. Perfect anatomic reduction not essential for
perfect function
 4. More potential growth= more remodeling
capability
 7 Principles
Dameron & Thompson JBJS 1959
 5. Restoration of alignment more important
than fragment position
 6. Over treatment usually worse than under
treatment
 7. Immobilize/splint injured limb before
definitive treatment
Treatment Goals - Restore

 Length
 Alignment
 Rotation
 Treatment Goals - Avoid

 Osteonecrosis - disruption of blood supply

to femoral head
 Physeal injury- preserve future growth
potential (proximal and distal femoral
physis, trochanteric apophysis)
 Complication of fracture femur
 Leg length
discrepancy
shortening
over growth
 Angular deformity
 Rotational deformity
 Delayed union
Complication of fracture femur

 Non union
 Muscle weakness
 Infection
 Neurovascular injury
 Compartment syndrome
 Decision Making
 Age
 Mechanism of injury
 Fracture pattern &
location
 Associated Injuries
 Surgeon preference
 Available resources
 Treatment options
 Age Treatment.
Birth to 24 mo padding & soft splint
Pavlik harness (newborn to 6 mo)
Immediate spica cast
Traction ~spica cast
2 yrs to 5 yrs Immediate spica cast
Traction ~ spica cast
External fixation (rare)
TEN (rare)
 Treatment options
6 yrs to 11 yrs Traction ~ spica cast
Compression plate
TEN
External fixation

12 yrs to maturity TEN

Compression plate
Locked IMN
External fixation
 Acceptable angulations
 Age Varus/ Anterior/ Shortening
Valgus Posterior (mm)
(degrees) (degrees)
Birth to 2yrs 30 30 15
2-5 yrs 15 20 20
6-10 yrs 10 15 15
11yrs to maturity 5 10 10
 Traction Techniques
 Skin or skeletal
 Longitudinal in line traction for comfort prior
to definitive treatment
 Longitudinal in line traction for comfort prior
to definitive treatment
 Traction Techniques

 Vertical over head

traction hip flexed 90
degree (Bryant 1973)
 Split Russells
traction (90-90) if
awaiting early
healing prior to
casting
 Skeletal Traction Techniques
 Avoid physis if place
skeletal traction pins
 Place pin perpendicular
to shaft to avoid
varus/valgus angulation
 Subtrochanteric fracture treated with traction
followed by one legged ambulatory spica cast
 Immediate Spica Cast-
ideal patient
 Less than 5 years old
 Less than 50 lbs
 Initial shortening not excessive
 Isolated injury

 Note -Spica casts used for decades and can

work for almost any pediatric femur fracture
 Spica Cast Technique
 Appropriate padding
 Cast liners may decrease
skin problems
 Traction to get 0-15 mm
shortening
 Mold laterally to prevent
varus
 Can wedge for
unacceptable angulation at
1-2 week
checkups
 Spica Cast
 Fiberglass lighter, easier
to x-ray through
 Often strong enough to
obviate need for
connecting bar
 Sitting spica – 3 part, 90-90

This technique, recommended in

textbooks and articles, may increase
risk of developing compartment
syndrome
Current technique – Above knee cast first.
Hip and knee- 40-45 flexion, foot out.
Can include opposite thigh if desired.
 Immediate Spica Cast
 X-ray weekly for 3
weeks
 Time in spica = age in
years + 3 weeks up to
maximum 8 weeks
 Wedge cast for
malalignment
 Rotational alignment
important at initial cast
application
 Complications
 Closed treatment of
children’s femur fractures
resulted in the most
frequent and expensive
complications, including
foot drop, skin loss,
compartment syndrome,
and malrotation /
shortening.
 Compartment syndrome complicating early
spica cast treatment of isolated femoral shaft
fractures in children
- JBJS Nov 03
Mold into slight
valgus desired on
initial radiograph
after casting
 Femoral Remodeling after
Fracture
 Will not correct significant
rotational malunion
(Davids, Clin Orthop)
 Overgrowth 1-1.5 cm may
occur, especially in
younger children treated
nonoperatively
 Angular deformity will
remodel significantly in
children <5 years old, less
reliably in 5-10 year old,
and is unlikely to be
substantial in children >10
years old
 Trend Toward More
Invasive Treatment
 More high energy fractures
 Improved operative techniques
 Failed nonoperative treatment
 Simplifies patient care
 Psychological, social and financial
reasons
 Ambulatory Treatment Options

 Plate & screw fixation

 External fixation
 Flexible nailing
 Rigid nailing
 Bridge plating / MIPPO/ locked plates
 Flexible Nailing
 Advantages
 Allows early
mobilization without cast
 Cosmetic scars
 Avoids physis and blood
supply to femoral head
12 yo male in RTA accident
Closed proximal third, oblique fracture
Back at school 2 weeks
Walking at 8 weeks
 Flexible Nailing
 Disadvantages
 Ends may irritate soft
tissues
 May not be amenable to
some fracture patterns
(very proximal or distal,
comminution)
 Flexible Nails
 Titanium elastic
intramedullary nailing
(TEIN)
 popular choice to
stabilize pediatric femur
fractures in children > 5
yrs
 little published on
complications
 JBJS Br 2006
Healed 5 cm short
 Most complications – minor

Nail Irritation (16%) -

don’t bend ends
- all resolved post
Cut pins above physis with screw
cutter
 13yo male, 94 lbs -nails too short, back out, get
infected, have to be removed, varus malunion with
shortening
 12 yr old female, 130 lbs
Varus, procurvatum malunion
TEIN yielded excellent or satisfactory results
in 90% of cases
Outcome was better in a higher percentage of
central-third fractures
Be aware of prox 1/3- mid 1/3
junction fracture with medial
butterfly
 Recommendations :
> 11 years, > 108 lbs
– consider other treatment options
 ORIF with Plates/Screws
 Advantages
 Anatomical reduction
 Rigid fixation
 Technique familiar to most surgeons
 Allows early motion
 Simplified nursing care
 Favorable results reported in children with
associated head injuries
 ORIF with Plates/Screws
 Disadvantages
 Large scar
 Implant failure
 Possible refracture after plate removed
 Second anaesthesia for implant removal
 Higher infection rate
ORIF Plate Fixation
Percutaneous Bridge
Plating
Previous fracture with endosteal
callus- plate good option
 External Fixation
 Advantages
 can be applied rapidly,
 allows soft tissue injury
management ,
 early mobilization,
 Good option in open
fractures & poly trauma
patients
 External Fixation
 Disadvantages
 pin site sepsis,
 pin site scarring,
 refracture,
 malunion
11 yrs male RSA
Pelvic fracture, ruptured bladder
External fixation
Ex Fix Fracture at Prox Pin

Keep pin diameter <20% of bone diameter.

Ex Fix Refracture

6 months post injury

 External Fixator Tips
 Appropriate size half pin diameter
 Proper pin placement relative to fracture for
biomechanical rigidity
 Do not remove ex fix until see bridging
cortices
Medium Multi-Pin Clamp

2cm
Clamp is
parallel
to bone
2cm Schanz
screw is
2cm perpendicular
to bone

2cm
 Open Femur Fracture
Principles
 IV antibiotics, tetanus
prophylaxis
 emergent irrigation &
debridement
 skeletal stabilization
 External fixation best
option with severe soft
tissue injury
 soft tissue coverage
 Open Fractures

Can use temporary shunting to

restore distal perfusion during
debridement
 Trochanteric Nail Technique
 Stay out of piriformis fossa
 Some use large incision/open approach
 Over ream/small nail - starting hole and canal
nonlinear
 Large diameter nail – ? benefit (no reported
nail fractures, nonunion rare)
 Piriformis Fossa Entry Site

Thometz J, JBJS 1995.

Astion D, JBJS 1995

Raney E. JPO, 1993.
 Anatomy- Blood Supply Proximal
Femoral Epiphysis
Predominantly ascending
cervical branch (B) of
medial circumflex femoral
artery
Physis (D) - a barrier to
intraosseous blood supply
from femoral neck
Ganz, et al
12 year old male, 6 mos
Small diameter solid nail, unreamed
 Trochanteric entry
Proximal and distal interlocking
Leave some bone medial to nail
 Nail removal
 Some controversy
 Commonly
recommended
 Survey studies – remove
IM devices in children
 Outpatient procedure
 Grasping pliers
 No sports for 4 weeks
 Return for x-ray
4 weeks post removal
 Summary
 < 5 years – early spica cast, changed technique
 5-11 years, < 100 lbs – TEN
 > 11, > 100 lbs – trochanteric entry nail or
bridge plating
 Very distal or very proximal fracture, closed
IM canal, or severe axial instability – bridge
plating
 Severe soft tissue injury- external fixation