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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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