Femur Fractures - Pediatric

Author: Chris Souder

Topic updated on 05/30/15 9:57pm
Introduction

 High suspicion for child abuse required

o abuse must be considered if child is < 5 years
 especially if present in a patient before walking age
o femur fractures are the 2nd most common child abuse associated
fracture after humerus fractures
 Epidemiology
o bimodal distribution
 increased rate in toddlers age 2-4 yrs.
 increased again in adolescents 
 Mechanism
o 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
o fractures after minor trauma can be the result of a pathologic
process
  bone tumors, OI, osteopenia, etc.

Classification
  Descriptive classification
o characteristics of the fracture
 transverse
 comminuted
 spiral etc.
o integrity of soft-tissue envelope
 open
 closed fracture
 Stability
o length stable fractures
 are typically transverse or short oblique
o length unstable fractures
 are spiral or comminuted fractures

Presentation
 Symptoms
o thigh pain, inability to walk, report of deformity or instability
 Physical exam
o gross deformity, shortening, swelling of the thigh

Imaging
 Radiographs
o AP and lateral of femur
 typically allow complete evaluation of the fracture location, configuration
and amount of displacement
o ipsilateral AP and lateral of knee and hip
 required to rule out associated injuries

Treatment
 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  Traction with delayed

  polytrauma/multiple spica casting  
fx/open fx  ORIF with submuscular
bridge plating
 Flexible nails
 External fixator

6 - 11 years  length stable fx  Flexible intramedullary

(transverse or oblique nails 
fx patterns)

 length unstable fx  ORIF with submuscular

(comminuted or spiral) bridge plating 
 very proximal or distal  External fixation 
fx o polytrauma patients
for damage control 

Approaching  length stable  Flexible intramedullary

skeletal  patient weighs < 100 nails
maturing (>11 lbs
years)

 length unstable  Antegrade IM nail

with trochanteric or lateral
 patient weighs > 100 lbs
starting point

 length unstable  ORIF with submuscular

 very proximal or distal fx bridge plating

Surgical Technqiues
 Pavlik harness
o indications
 children up to 6 mos.
o technique
 avoids the need for sedation or anesthesia
 straps can be adjusted to manipulate fracture
o 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   
o indications
 children 7 m - 5 years with < 2 - 3 cm of shortening
 relatively contraindicated with polytrauma, open fractures and shortening
 > 2-3 cm
o 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
o 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
o 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
o indications
 children 7 mos. - 5 yrs. of age with > 2 - 3 cm of shortening
o 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 
o 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
o 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
o follow up
 time to union is typically 10 - 12 weeks
 removal of the nail can be performed at 1 year
o 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 
o indications
 comminuted, length unstable fractures   
 very proximal or very distal fractures
o 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
o advantages
 stability allows for early mobility
 preserves blood supply to femoral head
 performed with minimal surgical exposure and soft-tissue dissection
o disadvantages
 steep learning curve
 load bearing implant
 multiple stress risers following removal of hardware
 Antegrade rigid intramedullary nail fixation 
o indications
 in patients > 11 years
  length unstable fractures
 fractures in patients weighing > 100 lbs
o technique
 use greater trochanter or lateral entry nails
 decreased risk of ON
 do not cross distal physis of femur
o advantages
 rigid fixation with interlocking screws control length and rotation
even in significantly unstable fractures
 permits early weightbearing
 decreased risk of angular malunion
o 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   
o 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
o 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
o 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%

Complications
 Leg-Length Discrepancy 
o 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
o 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   
o has been reported with piriformis and greater trochanter entry
nails
o femoral nailing through the piriformis fossa is contraindicated in
adolescents with open physes because of the risk of
osteonecrosis of femoral head
o 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 
o higher risk with load bearing devices
 external fixator or submuscular plates
o can occur after flexible intramedullary nailing in patients
  aged over 11 years old
  who weigh >49 kg (>108 lb)
 Malunion
o typical deformity is varus and flexion of the distal fragment
o remodeling is greatest in sagittal plane (ie flexion/extension
deformity)
o remodeling does not occur with rotational malalignment and
therefore must be corrected at the initial surgery
 rarely symptomatic
 Refracture
o most commonly seen after external fixator removal
o highest risk in transverse and short oblique fractures
  less likelihood of secondary callus formation

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