Femur Fractures - Pediatric

Author: Chris Souder

Topic updated on 04/03/13 7:53am

Introduction

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.

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
7m - 5 years	< 2 - 3 cm shortening	Early spica casting
7m - 5 years	> 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
6 - 11 years	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 stable 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 typical 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%

Complications

Leg-Length Discrepancy
- most common complication
- 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 (8 Questions)

TAG

(OBQ11.12) A 15-year-old child 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

PREFERRED RESPONSE ▶

DISCUSSION: 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.

Illustrations: A

REFERENCES:

1. Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg. 2004 Sep-Oct;12(5):347-59. PMID:15469229 (Link to Abstract)

2. Sponseller PD. Surgical management of pediatric femoral fractures. Instr Course Lect. 2002;51:361-5. PMID:12064126 (Link to Abstract)

3. MacNeil JA, Francis A, El-Hawary R. A systematic review of rigid, locked, intramedullary nail insertion sites and avascular necrosis of the femoral head in the skeletally immature. J Pediatr Orthop. 2011 Jun;31(4):377-80 PMID:21572274 (Link to Abstract)

Question Authors:

Terrill Julien MD, John Badylak MD, Eric Shirley MD,

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TAG

(OBQ11.43) An 11-year-old female sustains a 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

PREFERRED RESPONSE ▶

DISCUSSION: 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 managment in this population of pediatric patients.

REFERENCES:

1. Kocher MS, Sink EL, Blasier RD, Luhmann SJ, Mehlman CT, Scher DM, Matheney T, Sanders JO, Watters WC 3rd, Goldberg MJ, Keith MW, Haralson RH 3rd, Turkelson CM, Wies JL, Sluka P, Hitchcock K. Treatment of pediatric diaphyseal femur fractures. J Am Acad Orthop Surg. 2009 Nov;17(11):718-25. PMID:19880682 (Link to Abstract)

2. Moroz LA, Launay F, Kocher MS, Newton PO, Frick SL, Sponseller PD, Flynn JM. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. J Bone Joint Surg Br. 2006 Oct;88(10):1361-6. PMID:17012428 (Link to Abstract)

3. Wall EJ, Jain V, Vora V, Mehlman CT, Crawford AH. Complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures. J Bone Joint Surg Am. 2008 Jun;90(6):1305-13. PMID:18519325 (Link to Abstract)

4. Leet AI, Pichard CP, Ain MC. Surgical treatment of femoral fractures in obese children: does excessive body weight increase the rate of complications? J Bone Joint Surg Am. 2005 Dec;87(12):2609-13. PMID:16322608 (Link to Abstract)

Question Authors:

David Abbasi MD, John Badylak MD, Ben Taylor MD,

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TAG

(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

PREFERRED RESPONSE ▶

DISCUSSION: 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: A

REFERENCES:

2. Wall EJ, Jain V, Vora V, Mehlman CT, Crawford AH. Complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures. J Bone Joint Surg Am. 2008 Jun;90(6):1305-13. PMID:18519325 (Link to Abstract)

Question Authors:

Terrill Julien MD, Eric Shirley MD,

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TAG

(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

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359. PMID:15469229 (Link to Abstract)

2. Sponseller PD: Surgical management of pediatric femoral fractures. Instr Course Lect 2002;51:361-365. PMID:12064126 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore, Eric Shirley MD,

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TAG

(OBQ04.186) A 5-year-old boy sustains a midshaft femur fracture treated with closed reduction and hip-spica casting. What is the most common complication of this fracture in this age group? Topic

Review Topic

1. delayed union
2. nonunion
3. cosmetic deformity
4. leg-length discrepancy
5. rotational deformity

PREFERRED RESPONSE ▶

DISCUSSION: The most common complication after femoral shaft fractures in children is leg-length discrepancy. The discrepancy is not usually due to shortening, instead the concern is for accelerated overgrowth during healing. This is especially a concern in children aged 2-10 years, with an average overgrowth of 1.5cm. Therefore, acceptable reduction should include up to a maximum of 3cm of shortening. Overgrowth is associated with proximal 1/3 and oblique, comminuted fractures. The reference by Beatty reviews the diagnosis and treatment options for diaphyseal femur fractures in children and adolescents.

REFERENCES:

1. Beaty JH. Femoral-Shaft Fractures in Children and Adolescents. J Am Acad Orthop Surg. 1995 Jul;3(4):207-217. PMID:10795027 (Link to Abstract)

2. Canale ST, Beaty JH. Complications of femoral fractures, in Epps CH, Bowen JR (eds): Complications in Orthopaedic Surgery. Philadelphia, PA, JB Lippincott, 1995, pp 155-175

Question Authors:

Paul D. Kim MD, Derek Moore, Eric Shirley MD,

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TAG

(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

PREFERRED RESPONSE ▶

DISCUSSION: 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: A

REFERENCES:

1. Routt ML, Schildhauer T: Fractures of the femoral shaft, in Green NE, Swiontkowski MF (eds): Skeletal Trauma in Children, ed3. Philadelphia, PA, WB Saunders, 1998, pp 407-438

2. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 453-463

Question Authors:

Michael Hughes MD, Ben Taylor MD, Eric Shirley MD,

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TAG

(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. antegrade rigid femoral intramedullary nailing
4. external fixation
5. skeletal traction and spica casting

PREFERRED RESPONSE ▶

DISCUSSION: 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.

REFERENCES:

1. Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop. 2001 Jan-Feb;21(1):4-8. PMID:11176345 (Link to Abstract)

2. Bar-On E, Sagiv S, Porat S. External fixation or flexible intramedullary nailing for femoral shaft fractures in children. A prospective, randomised study. J Bone Joint Surg Br. 1997 Nov;79(6):975-8. Erratum in: J Bone Joint Surg Br 1998 Jul;80(4):749. PMID:9393916 (Link to Abstract)

3. Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma Trauma, ed 2. Philadelphia, PA,WB Saunders, 1992

Question Authors:

Paul D. Kim MD, Eric Shirley MD,

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Cases

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	femur fracture (C1439) Trauma - Treatment Consult - Femur Fractures - Pediatric HPI - had a fall fro a chair at home while playing.inabilty to move the lt lower limb.... operative intervention replating, plate removal and nailing	3/7/2013 198 responses 5

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Videos

	Pediatric Femur Flexible Intramedullary Nail Fixation Pediatrics - Surgical Techniques - Femur Fractures - Pediatric Dr John Flynn discusses of treatment of pediatric femur fractures with flexible...	7/26/2012 397 views 0
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Posts

Titanium Elastic Nailing of Fractures of the Femur in Children. Predictors of Complications and Poor Outcome. Includes Poll

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 Pubmed)

Pediatrics - Journal Club - Femur Fractures - Pediatric

4 weeks ago

29 responses

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Groups

ABOS II: Femur Fractures - Pediatric

General - Oral Boards Review

7/29/2011

0 responses

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Bar-On E, Sagiv S, Porat S. External fixation or flexible intramedullary nailing for femoral shaft fractures in children. A prospective, randomised study. J Bone Joint Surg Br. 1997 Nov;79(6):975-8. Erratum in: J Bone Joint Surg Br 1998 Jul;80(4):749. PMID:9393916 (Link to Abstract)

Level of Evidence 4 (Case Series)

Mendelson SA, Dominick TS, Tyler-Kabara E, Moreland MS, Adelson PD. Early versus late femoral fracture stabilization in multiply injured pediatric patients with closed head injury.J Pediatr Orthop. 2001 Sep-Oct;21(5):594-9 PMID:11521025 (Link to Abstract)
Hedequist D, Starr AJ, Wilson P, Walker J. Early versus delayed stabilization of pediatric femur fractures: analysis of 387 patients. J Orthop Trauma. 1999. Sep-Oct;13(7):490-3 PMID:10513971 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Hosalkar HS, Pandya NK, Cho RH, Glaser DA, Moor MA, Herman MJ. Intramedullary nailing of pediatric femoral shaft fracture. 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. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br. 2000 Jul;82(5):679-83 PMID:10963165 (Link to Abstract)
MacNeil JA, Francis A, El-Hawary R. A systematic review of rigid, locked, intramedullary nail insertion sites and avascular necrosis of the femoral head in the skeletally immature. J Pediatr Orthop. 2011 Jun;31(4):377-80 PMID:21572274 (Link to Abstract)
Kocher MS, Sink EL, Blasier RD, Luhmann SJ, Mehlman CT, Scher DM, Matheney T, Sanders JO, Watters WC 3rd, Goldberg MJ, Keith MW, Haralson RH 3rd, Turkelson CM, Wies JL, Sluka P, Hitchcock K. Treatment of pediatric diaphyseal femur fractures. J Am Acad Orthop Surg. 2009 Nov;17(11):718-25. Review. PMID:19880682 (Link to Abstract)
Routt ML, Schildhauer T: Fractures of the femoral shaft, in Green NE, Swiontkowski MF (eds): Skeletal Trauma in Children, ed3. Philadelphia, PA, WB Saunders, 1998, pp 407-438
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 453-463

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma Trauma, ed 2. Philadelphia, PA,WB Saunders, 1992

Undefined

Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg. 2004 Sep-Oct;12(5):347-59. PMID:15469229 (Link to Abstract)
Sponseller PD. Surgical management of pediatric femoral fractures. Instr Course Lect. 2002;51:361-5. PMID:12064126 (Link to Abstract)
Kocher MS, Sink EL, Blasier RD, Luhmann SJ, Mehlman CT, Scher DM, Matheney T, Sanders JO, Watters WC 3rd, Goldberg MJ, Keith MW, Haralson RH 3rd, Turkelson CM, Wies JL, Sluka P, Hitchcock K. Treatment of pediatric diaphyseal femur fractures. 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. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. 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. Complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures. J Bone Joint Surg Am. 2008 Jun;90(6):1305-13. PMID:18519325 (Link to Abstract)
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Femur Fractures - Pediatric

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