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Introduction
  • High suspicion for child abuse required 
    • abuse must be considered if child is < 3 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.
Classification
  •  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
Presentation
  • Symptoms
    • thigh pain, inability to walk, report of deformity or instability
  • Physical exam
    • gross deformity, shortening, swelling of the thigh
Imaging
  • 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
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
6m - 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
5 - 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 

11 or greater years

Shaft Fracture

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


Surgical Techniques
  • 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  
    • fewer complications than traction + later casting
    • indications
      • children 6 m - 5 years 
      • relatively contraindicated with polytrauma, open fractures and shortening > 2-3 cm
    • technique
      • applied with reduction under sedation or with GA
      • single-leg spica or one-and-one-half spica (to control rotation)
        • the exception is distal femoral buckle fracture (stable) only requires long leg cast (not spica)
      • hips flexed 60-90° and approximately 30° of abduction
      • 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 + delayed spica casting
    • indications
      • children 6 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
    • complications
      • more complications than immediate spica casting
  • Flexible intramedullary nails 
    • indications
      • treatment of choice for most simple, length stable fracture patterns in children 5 - 11 years 
      • adolescent patient weighing less than 100 lbs with a length stable fracture
    • technique
      • allows load sharing and quick mobilization 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
        • in up to 40% of patients
        • recommended that < 25mm of nail protrusion and minimal bend of the nail outside the femur are present
      • increased rate of complications in patients 11 years or up or > 50 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 (subtrochanteric) or very distal fractures (distal diaphyseal or metadiaphyseal)
    • technique
      • fracture is provisional reduced with closed or percutaneous techniques
      • small proximal + distal incisions and plate is placed between periosteum and vastus lateralis on the lateral side of the femur
      • typically use 12-16 hole 4.5mm narrow LC-DC plate with 3 screws proximal and 3 screws distal to fracture 
        • 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 or older
      • 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
      • more complications than internal fixation
      • 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 (1.5-21%) after removal of fixator especially with varus malunion
Complications
  • Leg-Length Discrepancy 
    • overgrowth
      • 0.7 - 2 cm is common in patients between 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  
    • reported with both 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 + flexion of the distal fragment
    • remodeling is greatest in sagittal plane (ie flexion/extension deformity)
    • rotational malalignment does not remodel 
      • must be corrected at the initial surgery
  • Refracture
    • most common after external fixator removal with varus malalignment
    • highest risk in transverse and short oblique fractures
    • less likelihood of secondary callus formation
 

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Technique Guides (2)
Questions (8)

(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? Review Topic

QID:4479
FIGURES:
1

Figure A

2%

(64/3895)

2

Figure B

91%

(3552/3895)

3

Figure C

2%

(82/3895)

4

Figure D

3%

(98/3895)

5

Figure E

2%

(79/3895)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

Piriformis entry intramedullary nails have been associated with damage to the deep branch of the medial femoral circumflex artery (MFCA) and a risk of avascular necrosis in children and adolescents.

Pediatric femoral shaft fractures have been successfully treated with a variety of methods including spica casting, traction, rigid intramedullary nails, elastic intramedullary nails, external fixation, and submuscular plating. Rigid intramedullary nails are usually considered when the patient is greater than 11 years of age and weighs more than 50kg. While trochaneric entry points may be used safely, piriformis entry nails carry an increased risk of damage to the blood supply to the femoral head and resulting osteonecrosis.

Hosalkar et al. reviewed intramedullary nailing (IMN) of pediatric femoral shaft fractures. They state the peripheral branches of the MFCA are close to the piriformis fossa, thus increasing the chances of osteonecrosis if piriformis entry nails are used.

Gautier et al. review the anatomy of the MFCA and its surgical implications. They conclude piriformis entry intramedullary nails increase the chances of osteonecrosis in adolescents because preparation for nail entry may damage the retinacular vessels as a result of the smaller relative femoral neck size in relation to the larger adult implant.

Figure B shows a piriformis entry starting point for an IMN. Illustration A shows the blood supply to the femoral head, with the posterior based MFCA.

Incorrect Answers:
Answers 1: Figure A shows a trochanteric entry point for an IMN, which is not associated with damage to the deep branch of the MFCA.
Answer 3: Figure C shows a cannulated hip screw, which is not associated with damage to the deep branch of the MFCA.
Answer 4: Figure D shows an external fixator, which is not associated with damage to the deep branch of the MFCA.
Answer 5: Figure E shows retrograde flexible nails, which is not associated with damage to the deep branch of the MFCA.

ILLUSTRATIONS:

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(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)? Review Topic

QID:3435
FIGURES:
1

Femoral nail with piriformis starting point

94%

(1976/2110)

2

Femoral nail with trochanteric starting point

2%

(46/2110)

3

Intramedullary flexible nails

1%

(14/2110)

4

Retrograde intramedullary nailing

1%

(20/2110)

5

External fixation with trochanteric fixation proximal

2%

(47/2110)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

Femoral nailing through a piriformis entry point has been shown to place the medial femoral circumflex artery (MFCA) at risk (Illustration A). Adolescents are at particular risk as the vascular supply to the growing hip and growth plates is at higher risk than greater trochanter tip and lateral entry IM nailing.

Flynn et al reviewed femur fractures in the pediatric population. While nonsurgical management includes spica casting, surgical management includes bridge plating, external fixation, retrograde flexible nails and antegrade flexible or solid nails with a greater trochanter entry point. AVN can occur with IM nailing, including a greater trochanter entry point. However, it carries the lower risk than the piriformis starting point.

Sponseller also reviewed pediatric femur fractures. He concluded that the several factors contribute to the decision-making algorithm for treatment. To adequately treat the patient, the surgeon should be very familiar with the surgical options for each age range.

MacNeil et al reviewed19 articles comparing locked IM nails with piriformis and greater trochanteric entry points. AVN rates for piriformis fossa entry point was 2.0% while greater trochanter tip entry AVN rate was 1.4%. There were no cases of AVN using the lateral entry of the greater trochanter.

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(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? Review Topic

QID:3466
1

Her age

3%

(59/2230)

2

Her height

1%

(22/2230)

3

Her weight

88%

(1973/2230)

4

Multiple extremity fractures

4%

(83/2230)

5

Open femur fracture

4%

(81/2230)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

This pediatric patient is obese and weighs 146 lbs, and would be at risk of increased complications including nonunion if she underwent elastic intramedullary nail fixation.

Kocher et al provide a review of pediatric femoral shaft fixation. Options include pavlik harness, spica casting, flexible intramedullary nailing, trochanteric nailing, and submuscular plating. They stated that patients aged over 11 years old, or who weigh >49 kg (>108 lb), are at increased risk of a poor outcome with flexible intramedullary nailing and therefore should not be used in this scenario.

Moroz et al showed that a poorer outcome after titanium elastic intramedullary nailing in pediatric patients was five times more likely in children over 11 years of age, and who weighed more than 49 kg. These results were statistically significant.

Wall et al compared the use of titanium elastic nails vs stainless steel elastic nails for pediatric femur fractures. They found femoral nonunion rates were 4X higher in the titanium elastic nail group (23.2% vs 6.3%). Their conclusion was that less expensive stainless steel elastic nails were superior to titanium nails due to much lower rate of malunion.

Leet et al found that obese children had increased rate of complications following surgical treatment for femoral shaft fractures. They conclude that preoperative discussion with parents of obese children should include the higher risk of complications after surgical management in this population of pediatric patients.


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

QID:3529
1

A 4-year-old boy with a spiral diaphyseal femur fracture

2%

(36/1623)

2

A 9-year-old, 75-lb girl with a length stable distal one-third femur fracture

7%

(121/1623)

3

A 10-year-old, 120-lb boy with a long spiral, comminuted midshaft femur fracture

85%

(1376/1623)

4

A 17-year-old girl with an open, transverse midshaft femur fracture

2%

(39/1623)

5

An 18-year-old female with a proximal third, wedge-shaped femur fracture

3%

(43/1623)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

Bridge plating is the best option for a 10 year old with contraindications to flexible nailing (Illustration A). Titanium flexible nails should be avoided in patients with length unstable fractures and in those with > 11 years of age and > 108 lbs. As the patient is 10 years old and has open physes, there are concerns with intramedullary nailing (greater troch or piriformis entry). Decision making varies among surgeons as to the appropriate age for far-lateral entry nailing.

Kocher et al reviewed pediatric diaphyseal femur fractures in the AAOS clinical practice guidelines. Current treatment recommendations are based on patient age, fracture characteristics, and family social situation. Evidence for treatment of fractures of children of various ages were graded as grade A (recommend), B (suggest), C (option) or unable to recommend for or against.

Wall et al investigated titanium versus stainless steel retrograde elastic nails in 104 pediatric patients. Malunion rates were approximately four times higher in the titanium group. In addition, the cost of titanium nails was over 3 times higher than stainless steel nails.

Incorrect answers:
1. A 4-year-old boy would best be treated in a spica cast.
2. A patient under 11 and under 110lbs with a length-stable fracture could be best treated with flexible nails or possiblly bridge plating.
4. A skeletally mature patient would be best treated with an IM nail.
5. A skeletally mature patient would be best treated with an IM nail.

ILLUSTRATIONS:

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(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? Review Topic

QID:188
1

iatrogenic femoral neck fracture

2%

(46/2218)

2

femoral head osteonecrosis

94%

(2080/2218)

3

femoral shaft non-union

1%

(13/2218)

4

nail breakage

0%

(6/2218)

5

proximal locking screw cutout

3%

(62/2218)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

Osteonecrosis following antegrade nailing of the femur in pediatric and adolescent patiens has been described and is believed to be the result of iatrogenic injury to the lateral epiphyseal branches of the medial circumflex femoral artery. These vessels, which lie adjacent to the piriformis fossa, are subject to direct trauma during the preparation of the femoral canal and during antegrade insertion of the intramedullary nail. Other general complications include: shortening, angular and rotational deformity, delayed union, nonunion, compartment syndrome, overgrowth, infection, skin problems, and scarring. The cited references are a useful review article and an ICL discussing the diagnosis and treatment of pediatric femoral shaft fractures.


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(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? Review Topic

QID:1291
1

delayed union

1%

(4/517)

2

nonunion

4%

(21/517)

3

cosmetic deformity

3%

(16/517)

4

leg-length discrepancy

36%

(184/517)

5

loss of reduction

56%

(292/517)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

Early hip spica cast treatment is the current mainstay of treatment in diaphyseal femur fractures in children less than 5 years of age. Complications of this treatment method are relatively low, but those requiring early revision of treatment most commonly involve loss of reduction.

Exact rates of complications following hip spica casting are difficult to isolate as there a variety of methods used to apply the casts in multiple positions.

Kocher et al suggested early hip spica casting with Level of evidence of II and a grade of B as the treatment of choice for diaphyseal femoral shaft fractures in children from 6 months to 5 years of age.

Earlier studies cite limb length discrepancy as the most common complication of femur fractures. However, Wright et al in 2005 demonstrated in a prospectively randomized study that malunion was approximately 3 times more common than limb length discrepancy. 11% of patients required a change in treatment for loss of reduction.

Delayed union, nonunion and cosmetic deformity are not common complications of hip spica treatment.

Limb length discrepancy is a feared complication of pediatric femoral shaft fractures as a result of overgrowth of the fractured limb. Early intervention is not needed as prescribed shortening in treatment is desired and time for overgrowth to occur requires later re-evaluation.


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(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? Review Topic

QID:1297
FIGURES:
1

Balanced skeletal traction

9%

(80/919)

2

External fixation

87%

(797/919)

3

Intramedullary nail with trochanteric starting point

3%

(26/919)

4

Intramedullary nail with pirifomis starting point

1%

(6/919)

5

Plate fixation

0%

(3/919)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

External fixation for this polytraumatized adolescent that is going to the operating room emergently for abdominal surgery is the most appropriate step, and can be thought of as damage control orthopaedics. External fixation of the comminuted femur fracture is shown in Illustration A. External fixators can be applied quickly and concurrent with general surgery during an exploratory laparotomy. Moreover, the femur can be effectively stabilized to allow for multiple transfers in the ICU/floor without disruption of the growth plate.

ILLUSTRATIONS:

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(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? Review Topic

QID:1311
FIGURES:
1

Closed reduction and hip spica casting

6%

(30/477)

2

Closed reduction and flexible intramedullary nailing

90%

(429/477)

3

Closed reduction and antegrade rigid femoral intramedullary nailing

1%

(7/477)

4

External fixation

1%

(4/477)

5

Skeletal traction and hip spica casting

1%

(6/477)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

Figure A demonstrates a transverse midshaft femur fractures in a skeletally immature patient. In this age bracket closed reduction and flexible intramedullary nailing is the best treatment option.

The reference by Flynn et al is a multicenter study looking at the results and complications of titanium elastic nailing. They found elastic nailing allowed rapid mobilization with few complications and excellent/satisfactory results in 57 of the 58 cases.

External fixation is an option, however, Bar-On et al in a prospective randomized trial comparing external fixation to flexible nailing showed that flexible nailing resulted in a quicker return to school and achievement of full ROM. They recommend reserving external fixation for open or severely comminuted fractures. The patient is too old and large for closed reduction and hip spica casting. Standard antegrade (intramedullary) IM nailing for patients younger than 12 years of age is not recommended because of possible proximal femoral growth abnormalities and osteonecrosis of the femoral head due to disruption of the vascular supply. Finally, skeletal traction and casting is an option, however not ideal because of the length of hospital stay required and immobilization required.


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