Approaching skeletal maturing (>11 years)
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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?
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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.
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.
Hosalkar HS, Pandya NK, Cho RH, Glaser DA, Moor MA, Herman MJ
J Am Acad Orthop Surg. 2011 Aug;19(8):472-81. PMID: 21807915 (Link to Abstract)
Gautier E, Ganz K, Krügel N, Gill T, Ganz R
J Bone Joint Surg Br. 2000 Jul;82(5):679-83. PMID: 10963165 (Link to Abstract)
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Average 4.0 of 7 Ratings
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)?
Femoral nail with piriformis starting point
Femoral nail with trochanteric starting point
Intramedullary flexible nails
Retrograde intramedullary nailing
External fixation with trochanteric fixation proximal
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.
Flynn JM, Schwend RM.
J Am Acad Orthop Surg. 2004 Sep-Oct;12(5):347-59. PMID: 15469229 (Link to Abstract)
Instr Course Lect. 2002;51:361-5. PMID: 12064126 (Link to Abstract)
MacNeil JA, Francis A, El-Hawary R
J Pediatr Orthop. 2011 Jun;31(4):377-80. PMID: 21572274 (Link to Abstract)
Average 4.0 of 15 Ratings
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?
Multiple extremity fractures
Open femur fracture
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.
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
J Am Acad Orthop Surg. 2009 Nov;17(11):718-25. PMID: 19880682 (Link to Abstract)
Moroz LA, Launay F, Kocher MS, Newton PO, Frick SL, Sponseller PD, Flynn JM
J Bone Joint Surg Br. 2006 Oct;88(10):1361-6. PMID: 17012428 (Link to Abstract)
Wall EJ, Jain V, Vora V, Mehlman CT, Crawford AH.
J Bone Joint Surg Am. 2008 Jun;90(6):1305-13. PMID: 18519325 (Link to Abstract)
Leet AI, Pichard CP, Ain MC.
J Bone Joint Surg Am. 2005 Dec;87(12):2609-13. PMID: 16322608 (Link to Abstract)
Average 3.0 of 18 Ratings
Which of the following patients would be the BEST candidate for submuscular bridge plating?
A 4-year-old boy with a spiral diaphyseal femur fracture
A 9-year-old, 75-lb girl with a length stable distal one-third femur fracture
A 10-year-old, 120-lb boy with a long spiral, comminuted midshaft femur fracture
A 17-year-old girl with an open, transverse midshaft femur fracture
An 18-year-old female with a proximal third, wedge-shaped femur fracture
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.
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.
Average 3.0 of 25 Ratings
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?
iatrogenic femoral neck fracture
femoral head osteonecrosis
femoral shaft non-union
proximal locking screw cutout
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.
Average 4.0 of 11 Ratings
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?
loss of reduction
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.
Wright JG, Wang EE, Owen JL, Stephens D, Graham HK, Hanlon M, Nattrass GR, Reynolds RA, Coyte P.
Lancet. 2005 Mar 26-Apr 1;365(9465):1153-8. PMID: 15794970 (Link to Abstract)
Frech-Dörfler M, Hasler CC, Häcker FM.
Eur J Pediatr Surg. 2010 Jan;20(1):18-23. Epub 2009 Oct 28. PMID: 19866412 (Link to Abstract)
Average 3.0 of 21 Ratings
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?
Balanced skeletal traction
Intramedullary nail with trochanteric starting point
Intramedullary nail with pirifomis starting point
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.
Average 3.0 of 14 Ratings
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?
Closed reduction and hip spica casting
Closed reduction and flexible intramedullary nailing
Closed reduction and antegrade rigid femoral intramedullary nailing
Skeletal traction and hip spica casting
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.
Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J
J Pediatr Orthop. 2001 Jan-Feb;21(1):4-8. PMID: 11176345 (Link to Abstract)
Bar-On E, Sagiv S, Porat S.
J Bone Joint Surg Br. 1997 Nov;79(6):975-8. PMID: 9393916 (Link to Abstract)
Average 4.0 of 21 Ratings
HPI - S/p car accident 5/4/2015
How would you classify this fracture on initial injury?
HPI - Was injured in a car accident two years ago and sustained left hip fracture-dislocation. Was immediately treated with reduction and ASNIS screw fixation. Screws were already removed at the time the patient seeked our opinion.
How would you treat this patient?
HPI - had a fall fro a chair at home while playing.inabilty to move the lt lower limb.operated on the same femur 2 yrs ago.then shae had a fracture with a lot of femur bowing.bow ing was corrected with an osteotomy and a locking plate was applied
operative intervention replating, plate removal and nailing
HPI - Struck by a car. Sustained a closed segmental subtrochanteric proximal femoral fracture on the right. Also sustained an open fracture to the left tibia (GA score of 3A).
How would you manage a closed segmental subtrochanteric proximal femoral fracture in a 10 year old
Dr John Flynn discusses of treatment of pediatric femur fractures with flexible...
An example of how a child is fitted with a Spica Cast after a hip reduction surg...