Femoral Shaft Fractures - Pediatric

Topic updated on 08/27/16 12:59pm
  • High suspicion for child abuse required 
    • abuse must be considered if child is < 5 years
      • especially if present in a patient before walking age
    • femur fractures are the 2nd most common child abuse associated fracture after humerus fractures
  • Epidemiology
    • bimodal distribution
      • increased rate in toddlers age 2-4 yrs.
      • increased again in adolescents 
  • Mechanism
    • correlated with age due to the increasing thickness of the cortical shaft during skeletal growth and maturity
      • falls most common cause in toddlers
      • high energy trauma is responsible for second peak in adolescents
        • MVC or ped vs vehicle
    • fractures after minor trauma can be the result of a pathologic process
      • bone tumors, OI, osteopenia, etc.
  •  Descriptive classification
    • characteristics of the fracture
      • transverse
      • comminuted
      • spiral etc.
    • integrity of soft-tissue envelope
      • open
      • closed fracture
  • Stability
    • length stable fractures
      • are typically transverse or short oblique
    • length unstable fractures
      • are spiral or comminuted fractures
  • Symptoms
    • thigh pain, inability to walk, report of deformity or instability
  • Physical exam
    • gross deformity, shortening, swelling of the thigh
  • Radiographs
    • AP and lateral of femur
      • typically allow complete evaluation of the fracture location, configuration and amount of displacement
    • ipsilateral AP and lateral of knee and hip
      • required to rule out associated injuries
  • Based on age and size of patient and fracture pattern
  • Guidelines provided by AAOS 
Treatment Guidelines
< 6 months
  • Any fx pattern
  • Pavlik harness 
  • Early spica casting
7m - 5 years
  • < 2 - 3 cm shortening
  • Early spica casting 
  • > 2 - 3 cm shortening
  • polytrauma/multiple fx/open fx
  • Traction with delayed spica casting  
  • ORIF with submuscular bridge plating
  • Flexible nails
  • External fixator
6 - 11 years
  • length stable fx (transverse or oblique fx patterns)
  • Flexible intramedullary nails   
  • length unstable fx (comminuted or spiral)
  • very proximal or distal fx
  • ORIF with submuscular bridge plating  
  • External fixation 
    • polytrauma patients for damage control 

Approaching skeletal maturing (>11 years)

  • length stable
  • patient weighs < 100 lbs
  • Flexible intramedullary nails  
  • length unstable
  • patient weighs > 100 lbs
  • Antegrade IM nail with trochanteric or lateral starting point
  • length unstable
  • very proximal or distal fx
  • ORIF with submuscular bridge plating

Surgical Technqiues
  • Pavlik harness
    • indications
      • children up to 6 mos.
    • technique
      • avoids the need for sedation or anesthesia
      • straps can be adjusted to manipulate fracture
    • complications
      • can compress femoral nerve if excessive hip flexion is used in presence of a swollen thigh
        • identified by decreased quadricep function
  • Immediate spica casting  
    • indications
      • children 7 m - 5 years with < 2 - 3 cm of shortening
      • relatively contraindicated with polytrauma, open fractures and shortening > 2-3 cm
    • technique
      • applied with reduction under sedation or with general anesthesia
      • hips are flexed 60-90° and are placed in approximately 30° of abduction
      • knees are placed in 90° of flexion
        • MUST limit compression and/or traction thru popliteal fossa
      • external rotation is typically needed to correct rotational deformity
      • molds along the distal femoral condyles and buttocks help to maintain reduction
      • acceptable limits are based on childs age
        • goal of reduction should include obtaining < 10° of coronal plane and < 20° of sagittal plane deformity with no more than 2cm of shortening or 10° of rotational malalignment
      • a special car seat is needed for transport
    • follow-up
      • weekly radiographs to monitor for loss of reduction for first 2 to 3 weeks
        • cast wedging can be used to correct deformities 
      • healing times vary from 4 - 8 weeks based on age
    • complications
      • compartment syndrome
        • decreased with applying smooth contours around popliteal fossa, limiting knee flexion to < 90° and avoiding excessive traction
        • monitored for by observing the child's neurovascular exam and level of comfort
  •  Traction with delayed spica casting
    • indications
      • children 7 mos. - 5 yrs. of age with > 2 - 3 cm of shortening
    • technique
      • placed in distal femur proximal to distal femoral physis
        • proximal tibial traction can cause recurvatum due to damage to the tibial tubercle apophysis
      • used for 2-3 weeks to allow early callus formation
      • spica casting then applied until fracture healing
  • Flexible intramedullary nails 
    • indications
      • treatment of choice for most simple, length stable fracture patterns in children 6 - 10 years 
      • adolescent patient weighing less than 100 lbs with a length stable fracture
    • technique
      • allows load sharing and quick moblization of the patient
      • nail size determined by multiplying width of narrowest portion of femoral canal by 0.4
        • the goal is 80% canal fill
      • two nails of equal size are inserted retrograde beginning approximately 2 -2.5 cm above the distal femoral physis
    • follow up
      • time to union is typically 10 - 12 weeks
      • removal of the nail can be performed at 1 year
    • complications
      • most common complication is pain at insertion site near the knee
        • reported in up to 40% of patients
        • recommended that less than 25mm of nail protrusion and minimal bend of the nail outside the femur are present
      • increased rate of complications in patients >11 - 12 years of age or > 45 kg 
      • increased rates of malunion and shortening in very proximal and distal fractures, as well as significantly comminuted fractures
  • Submuscular bridge plate fixation 
    • indications
      • comminuted, length unstable fractures  
      • very proximal or very distal fractures
    • technique
      • fracture is provisional reduced with closed or percutaneous techniques
      • small incisions are made proximally and distally and a plate is placed between the periosteum and vastus lateralis on the lateral side of the femur
      • a 12 to 16 hole 4.5mm narrow LC-DC plate with 3 screws proximal and 3 screws distal to the fracture will typically suffice
        • the plate may need to be bent to accomodate the natural bend of the femur
        • locking fixation can be used in osteoporotic areas or in very proximal or very distal fractures with limited area for fixation
      • weightbearing is restricted until visible callus formation at an average of 5 weeks
    • advantages
      • stability allows for early mobility
      • preserves blood supply to femoral head
      • performed with minimal surgical exposure and soft-tissue dissection
    • disadvantages
      • steep learning curve
      • load bearing implant
      • multiple stress risers following removal of hardware
  • Antegrade rigid intramedullary nail fixation 
    • indications
      • in patients > 11 years
      • length unstable fractures
      • fractures in patients weighing > 100 lbs
    • technique
      • use greater trochanter or lateral entry nails
        • decreased risk of ON
      • do not cross distal physis of femur
    • advantages
      • rigid fixation with interlocking screws control length and rotation even in significantly unstable fractures
      • permits early weightbearing
      • decreased risk of angular malunion
    • complications
      • ON risk is 1-2% with piriformis start in a patient with open proximal physes
      • exact risk of ON with greater trochanter and lateral entry nails is unknown
      • secondary deformities of the proximal femur can occur after greater trochanteric insertions
        • narrowing of the femoral neck
        • premature fusion of greater trochanter apophysis
        • coxa valga
        • hip subluxation
  • External fixation  
    • indications
      • damage control orthopaedics in a polytrauma patient  
      • open fractures 
      • associated vascular injuries requiring revascularization
      • fractures with associated soft tissue concerns
      • segmental or significantly comminuted fractures
      • multiply injured patient
    • technique
      • applied laterally
        • avoid disruption and scarring of quadriceps
      • 10 - 16 weeks of fixation is typically needed for solid union to occur
      • weightbearing as tolerated can be considered with stiff constructs
    • complications
      • pin tract infections are frequent
        • as high as 50% of fixator related complications
        • treated with oral antibiotics and pin site care
      • higher rates of delayed union, nonunion and malunion
      • increased risk of refracture after removal of fixator
        • 1.5 - 21%
  • Leg-Length Discrepancy 
    • overgrowth
      • 0.7 - 2 cm is common in patients between the ages of 2 - 10 years at time of fracture
      • typically presents within 2 years of injury
    • shortening
      • is acceptable if less than 2 - 3 cm because of anticipated overgrowth
      • can be symptomatic if greater than 2 - 3 cm 
        • temporary traction or internal fixation used to prevent persistent shortening
  • Osteonecrosis (ON) of femoral head  
    • has been reported with piriformis and greater trochanter entry nails
    • femoral nailing through the piriformis fossa is contraindicated in adolescents with open physes because of the risk of osteonecrosis of femoral head
    • main supply to femoral head is deep branch of the medial femoral circumflex artery 
      • branches into superior retinacular vessels that supply the femoral head 
      • vulnerable as it lies near the piriformis fossa
  • Nonunion 
    • higher risk with load bearing devices
      • external fixator or submuscular plates
    • can occur after flexible intramedullary nailing in patients
      •  aged over 11 years old
      •  who weigh >49 kg (>108 lb)
  • Malunion
    • typical deformity is varus and flexion of the distal fragment
    • remodeling is greatest in sagittal plane (ie flexion/extension deformity)
    • remodeling does not occur with rotational malalignment and therefore must be corrected at the initial surgery
      • rarely symptomatic
  • Refracture
    • most commonly seen after external fixator removal
    • highest risk in transverse and short oblique fractures
      • less likelihood of secondary callus formation


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Qbank (16 Questions)

(OBQ12.119) Which of the following techniques used to treat pediatric femur fractures has been associated with the greatest risk of damage to the deep branch of the medial femoral circumflex artery? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

(OBQ11.12) An 11-year-old male falls and sustains the injury shown in Figure A. Which of the following treatment options carries the greatest risk of injury to the medial femoral circumflex artery (MFCA)? Topic Review Topic
FIGURES: A          

1. Femoral nail with piriformis starting point
2. Femoral nail with trochanteric starting point
3. Intramedullary flexible nails
4. Retrograde intramedullary nailing
5. External fixation with trochanteric fixation proximal

(OBQ11.43) An 11-year-old female sustains an open right femoral shaft fracture and closed left both-bone forearm fracture after being struck by a motor vehicle. She is 5'1'' and weighs 146 lbs. No neurovascular deficits are noted in any of her extremities. Which of the following is a contraindication to elastic intramedullary nail fixation of her femur fracture? Topic Review Topic

1. Her age
2. Her height
3. Her weight
4. Multiple extremity fractures
5. Open femur fracture

(OBQ11.106) Which of the following patients would be the BEST candidate for submuscular bridge plating? Topic Review Topic

1. A 4-year-old boy with a spiral diaphyseal femur fracture
2. A 9-year-old, 75-lb girl with a length stable distal one-third femur fracture
3. A 10-year-old, 120-lb boy with a long spiral, comminuted midshaft femur fracture
4. A 17-year-old girl with an open, transverse midshaft femur fracture
5. An 18-year-old female with a proximal third, wedge-shaped femur fracture

(OBQ06.77) A 14-year-old boy sustains a femoral shaft fracture while waterskiing. He is treated with a piriformis fossa entry antegrade intramedullary nail. Six months post-operatively the patient complains of persistent groin pain. What is the most likely complication he has sustained? Topic Review Topic

1. iatrogenic femoral neck fracture
2. femoral head osteonecrosis
3. femoral shaft non-union
4. nail breakage
5. proximal locking screw cutout

(OBQ04.186) A 4-year-old boy sustains a midshaft femur fracture with less than 2 cm of shortening that was treated with immediate closed reduction and hip-spica casting. Of the following listed potential complications, which is the most common requiring revision treatment in this age group? Topic Review Topic

1. delayed union
2. nonunion
3. cosmetic deformity
4. leg-length discrepancy
5. loss of reduction

(OBQ04.192) A 13-year-old male is involved in motor vehicle accident. He has a GCS of 6 and is intubated at the scene. He has a splenic laceration that will require an emergent exploratory laparotomy and he has a left hemothorax requiring a chest tube. His femur fracture is shown in Figure A. What is the next best step in management of this fracture? Topic Review Topic
FIGURES: A          

1. Balanced skeletal traction
2. External fixation
3. Intramedullary nail with trochanteric starting point
4. Intramedullary nail with pirifomis starting point
5. Plate fixation

(OBQ04.206) A 7-year-old boy sustains an isolated, closed injury shown in Figure A. He weighs 55lbs and is otherwise healthy. What is the best treatment option for this patient? Topic Review Topic
FIGURES: A          

1. Closed reduction and hip spica casting
2. Closed reduction and flexible intramedullary nailing
3. Closed reduction and antegrade rigid femoral intramedullary nailing
4. External fixation
5. Skeletal traction and hip spica casting

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