Introduction Overview pediatric femoral shaft fractures are one of the most common pediatric orthopedic fractures and are the most common reason for pediatric hospitalization due to orthopedic injury treatment may be casting or operative depending on the fracture pattern and age of patient any femur fracture in a child not yet walking should raise concern for non-accidental trauma Epidemiology incidence 1.6-2% of all pediatric fractures bimodal distribution increased rate in toddlers age 2-4 years and adolescents most common reason for pediatric hospitalization due to orthopaedic injury demographics males more commonly affected 2.6:1 Pathophysiology mechanism of injury fall is the most common cause < 10 years old motor vehicle accident is the most common cause > 10 years old correlated with age due to the increased thickness of the cortical shaft during skeletal growth and maturity Associated conditions high suspicion for child abuse required abuse must be considered if the child is < 3 years and especially if present in a patient before walking age femur fractures are one of the most common fractures associated with child abuse Transverse fractures more predictive of non-accidental trauma compared to spiral or oblique fractures medical conditions and comorbidities osteogenesis imperfecta osteopenia secondary to neuromuscular disorders benign or malignant bone tumors Prognosis high rate of fracture union if appropriate treatment is selected based on patient age and fracture pattern timing of surgical intervention early surgical intervention (< 24-48 hours) of femur fractures in the setting of a closed head injury leads to decreased length of hospital stay and is not associated with an increase in pulmonary complications Anatomy Osteology anterior bow to femur isthmus is the narrowest portion of the femur Muscles iliopsoas creates a flexion and external rotation force on the proximal fragment adductors create a shortening and varus force on the distal fragment Biomechanics femoral shaft cortical diameter and cortical thickness increase with age Classification Descriptive classification characteristics of the fracture transverse comminuted spiral others location of the fracture proximal, middle, or distal third integrity of the soft-tissue envelope open vs. closed fracture Stability stable fractures typically transverse or short oblique unstable fractures long spiral (fracture length > 2x bone diameter at that level) comminuted 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 the femur allow for complete evaluation of the fracture location, configuration, and amount of displacement ipsilateral AP and lateral of knee and hip to rule out associated injuries Treatment Nonoperative Pavlik harness indications children < 6 months old any fracture pattern spica casting indications children 0-5 years old relatively contraindicated with polytrauma, open fractures and shortening > 2-3 cm traction + delayed spica casting indications younger patients with significant shortening rarely utilized Operative flexible intramedullary nails indications most length stable fracture patterns in children 5-11 years old weighing < 49kg (100 lbs) submuscular bridge plate fixation indications unstable fractures in children > 5 years old and > 49kg (100lbs) very proximal or very distal fractures severe comminution antegrade rigid intramedullary nail fixation indications in patients > 11 years old or approaching skeletal maturity unstable fractures fractures in patients weighing > 49kg (100 lbs) external fixation indications damage control orthopedics in a polytrauma patient open fractures associated vascular injuries requiring revascularization segmental or significantly comminuted fractures Treatment Table by Age < 6 months • any fracture pattern • Pavlik harness • early spica casting 6 months - 5 years • stable fracture pattern • early spica casting • unstable fracture pattern • polytrauma, multiple/open fx • traction with delayed spica casting • external fixator 5-11 years • length stable and <49kg • flexible titanium nails • length unstable fx (comminuted or spiral) • very proximal or distal fx • any weight • ORIF with submuscular bridge plating • stainless steel Enders nails • external fixation > 11 years • patient weighs > 49kg (100 lbs) • antegrade rigid intramedullary nail fixation • proximal or distal fx • severe comminution • ORIF with submuscular bridge plating Surgical Techniques Pavlik harness technique avoids the need for sedation or anesthesia complications can compress femoral nerve if excessive hip flexion is used in presence of a swollen thigh identified by decreased quadriceps function Immediate spica casting technique applied with reduction under sedation or with general anesthesia single-leg spica or one-and-one-half spica (to control rotation) distal femoral buckle fracture may be treated with long leg cast alone (not spica) hips flexed 60-90° and approximately 30° of abduction external rotation is typically needed to correct a rotational deformity molded into recurvatum and valgus as the muscular forces will pull fracture into procurvatum and varus molds along the distal femoral condyles and buttocks help to maintain reduction acceptable limits are based on age the 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 sometimes needed for transport (often can use a regular car seat if single-leg spica is used) complications compartment syndrome be careful to apply with smooth contours in popliteal fossa, do not flex knee >90, and avoid excessive traction outcomes healing times vary from 4-8 weeks based on age Traction + delayed spica casting 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 more complications than immediate spica casting Flexible intramedullary nails approach all distal approach 2cm incision medially and laterally at level of distal physis spread with hemostat to starting point 2cm proximal to physis distal and proximal approach 2cm incision laterally at level of distal physis and 2cm incision proximally at greater troch apophysis instrumentation nail size determined by multiplying the width of the isthmus of femoral canal by 0.4 the goal is 80% canal fill complications the 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 malunion increased rates with comminuted, shortened, or very proximal/distal fractures outcomes generally good outcomes time to union is typically 10-12 weeks removal of the nail can be performed at 1 year Submuscular bridge plate fixation approach laterally based incision and plating with minimal disruption of soft tissue envelope small proximal and distal incisions and plate is placed between periosteum and vastus lateralis on the lateral side of the femur fracture is provisionally reduced with closed or percutaneous techniques instrumentation typically use 12-16 hole 4.5mm narrow LC-DC plate with 3 screws proximal and 3 screws distal to the fracture plate may need to be bent to accommodate the natural bend of the femur contoured femur plates are also an option complications hardware removal refracture following hardware removal outcomes favorable time to union, weight bearing, hardware irritation, and limp outcomes Antegrade rigid intramedullary nail fixation approach trochanteric entry nail lateral entry nail avoid piriformis entry due to risk of injury to vascularity to femoral head soft tissue lateral incision proximal to the greater trochanter sharp or electrocautery through fascia lata to obtain starting point at the tip of the greater trochanter closed versus open reduction of the fracture instrumentation with fracture reduced follow steps to insert intramedullary nail with caution to not cross distal physis complications osteonecrosis risk is 1-2% with piriformis start in a patient with open proximal physes the exact risk of osteonecrosis 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 outcomes decreased risk of angular malunion favorable outcomes in adolescents External fixation technique applied laterally avoid disruption and scarring of quadriceps 10-16 weeks of fixation is typically needed for solid union weight-bearing weight-bearing 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 the most common complication in younger patients 0.7 - 2 cm is common in patients <10 years typically occurs within 2 years of injury shortening is acceptable if less than 2 - 3 cm because of anticipated overgrowth in young patients can be symptomatic if greater than 2 - 3 cm temporary traction or fixation used to prevent persistent shortening Osteonecrosis (ON) of the 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 and malunion 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) the typical deformity is varus + flexion of the distal fragment remodeling is greatest in the sagittal plane rotational malalignment does not remodel nearly 50% of fractures treated with flexible nails have 15 degrees of malalignment Refracture most common after external fixator removal with varus alignment
Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Spica Casting for Femur Fractures Lindsay Andras Paul Choi Pediatrics - Femoral Shaft Fractures - Pediatric Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Flexible IMN for Femur Fractures Lindsay Andras Deirdre Ryan Pediatrics - Femoral Shaft Fractures - Pediatric
QUESTIONS 1 of 39 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ16.195) An 8-year-old male was seen in the emergency department with his parents after being struck by a car while riding his bicycle. He was found to have the injury seen in Figure A. Which of the following treatment modalities is most appropriate for treating this injury? Tested Concept QID: 8957 FIGURES: A Type & Select Correct Answer 1 Piriformis entry femoral nail 1% (19/2186) 2 Flexible intramedullary nail 48% (1055/2186) 3 ORIF with plate and screws 40% (883/2186) 4 Trochanteric entry femoral nail 3% (67/2186) 5 Spica casting 7% (153/2186) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ13PE.118) A 3-year-old male sustains the injury shown in Figure A and an immediate hip spica is placed. Over the next 24-hours the patient is noted to become agitated with increasing analgesia requirements and decreased movement of his left toes. All of the following factors may lead to this condition EXCEPT: Tested Concept QID: 5379 FIGURES: A Type & Select Correct Answer 1 Spica casting with knee flexed 105-degrees 5% (147/3000) 2 Immediate cast placement in the emergency department under conscious sedation 57% (1706/3000) 3 Initial placement of short leg cast for traction to aid in fracture reduction 30% (909/3000) 4 Firm cast mold in popliteal fossa to prevent fracture displacement 2% (71/3000) 5 High energy injury 2% (68/3000) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (SBQ13PE.39) Antegrade rigid intramedullary nailing with a trochanteric entry nail is appropriate for which of the following? Tested Concept QID: 5063 Type & Select Correct Answer 1 A 2-month-old female with displaced, spiral, mid-diaphyseal femur fracture 0% (1/2577) 2 A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with <2cm shortening 1% (28/2577) 3 A 7-year old boy with a transverse, non-comminuted mid-diaphyseal femur fracture 4% (94/2577) 4 A 7-year-old boy with a highly comminuted mid-diaphyseal femur fracture 3% (77/2577) 5 A 15-year-old girl with a displaced butterfly fragmented mid-diaphyseal femur fracture 88% (2276/2577) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (SBQ13PE.38) For which of the following patients is Pavlik harness treatment appropriate? Tested Concept QID: 5059 Type & Select Correct Answer 1 4-month-old with a diaphyseal femur fracture and a neuromuscular disorder with lower extremity spasticity 1% (31/2174) 2 4-month-old with a displaced spiral mid-diaphyseal femur fracture 80% (1742/2174) 3 4-month-old with a diaphyseal femur fracture and concomitant closed head injury and chest trauma 12% (256/2174) 4 9-month-old with a diaphyseal femur fracture with <2cm shortening 2% (39/2174) 5 9-month-old with a diaphyseal femur fracture with >2cm shortening 1% (14/2174) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (SBQ13PE.40) Immediate spica casting is most appropriate for which of the following?: Tested Concept QID: 5067 Type & Select Correct Answer 1 2-month-old girl with a displaced spiral mid-diaphyseal femur fracture 15% (516/3354) 2 A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with <2 centimeters of shortening 78% (2624/3354) 3 3-day-old with teratologic right hip dislocation 2% (69/3354) 4 9-year-old boy with a displaced spiral mid-diaphyseal femur fracture 1% (25/3354) 5 12-year-old girl weighing 90 pounds with a displaced spiral mid-diaphyseal femur fracture 0% (9/3354) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (SBQ13PE.42) Submuscular bridge plating is appropriate treatment for which of the following? Tested Concept QID: 5075 Type & Select Correct Answer 1 A 2-month-old female with displaced, spiral, mid-diaphyseal femur fracture 0% (5/2958) 2 A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with <2cm shortening 1% (24/2958) 3 A 7-year old boy with a transverse, non-comminuted mid-diaphyseal femur fracture 3% (85/2958) 4 A 7-year-old boy with a highly comminuted mid-diaphyseal femur fracture 82% (2439/2958) 5 A 15-year-old girl with a displaced butterfly fragmented mid-diaphyseal femur fracture 8% (222/2958) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ13PE.41) Titanium elastic nailing is appropriate treatment for which of the following? Tested Concept QID: 5071 Type & Select Correct Answer 1 A 2-month-old female with displaced, spiral, mid-diaphyseal femur fracture 0% (9/2397) 2 A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with <2cm shortening 1% (31/2397) 3 A 10-year-old boy who weighs 35 kilograms with a highly comminuted diaphyseal femur fracture 2% (47/2397) 4 A 10-year-old boy who weighs 35 kilograms with a transverse, mid-diaphyseal femur fracture 89% (2144/2397) 5 A 10-year-old boy who weighs 51 kilograms with a transverse, mid-diaphyseal femur fracture 2% (55/2397) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 4479 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 2% (77/4602) 2 Figure B 91% (4178/4602) 3 Figure C 2% (104/4602) 4 Figure D 3% (120/4602) 5 Figure E 2% (93/4602) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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)? Tested Concept QID: 3435 FIGURES: A Type & Select Correct Answer 1 Femoral nail with piriformis starting point 93% (2552/2748) 2 Femoral nail with trochanteric starting point 2% (65/2748) 3 Intramedullary flexible nails 1% (24/2748) 4 Retrograde intramedullary nailing 1% (24/2748) 5 External fixation with trochanteric fixation proximal 3% (71/2748) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ11.106) Which of the following patients would be the BEST candidate for submuscular bridge plating? Tested Concept QID: 3529 Type & Select Correct Answer 1 A 4-year-old boy with a spiral diaphyseal femur fracture 3% (59/2115) 2 A 9-year-old, 75-lb girl with a length stable distal one-third femur fracture 8% (163/2115) 3 A 10-year-old, 120-lb boy with a long spiral, comminuted midshaft femur fracture 83% (1761/2115) 4 A 17-year-old girl with an open, transverse midshaft femur fracture 3% (55/2115) 5 An 18-year-old female with a proximal third, wedge-shaped femur fracture 3% (63/2115) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (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? Tested Concept QID: 3466 Type & Select Correct Answer 1 Her age 3% (75/2969) 2 Her height 1% (30/2969) 3 Her weight 88% (2616/2969) 4 Multiple extremity fractures 4% (106/2969) 5 Open femur fracture 4% (119/2969) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07PE.52) Figure 22 shows the radiograph of a 7-year-old boy who underwent retrograde elastic nailing of a femoral shaft fracture. What is the most common problem following this procedure? Tested Concept QID: 6112 FIGURES: A Type & Select Correct Answer 1 Unacceptable shortening 1% (3/238) 2 Osteonecrosis of the femoral head 0% (0/238) 3 Malunion 3% (8/238) 4 Persistent pain and irritation at the nail insertion site 66% (156/238) 5 Rotational malalignment 26% (61/238) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (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? Tested Concept QID: 188 Type & Select Correct Answer 1 iatrogenic femoral neck fracture 2% (75/3263) 2 femoral head osteonecrosis 94% (3063/3263) 3 femoral shaft non-union 1% (22/3263) 4 nail breakage 0% (9/3263) 5 proximal locking screw cutout 2% (78/3263) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 1291 Type & Select Correct Answer 1 delayed union 1% (6/894) 2 nonunion 3% (29/894) 3 cosmetic deformity 3% (29/894) 4 leg-length discrepancy 34% (306/894) 5 loss of reduction 58% (521/894) L 5 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (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? Tested Concept QID: 1311 FIGURES: A Type & Select Correct Answer 1 Closed reduction and hip spica casting 6% (43/770) 2 Closed reduction and flexible intramedullary nailing 90% (696/770) 3 Closed reduction and antegrade rigid femoral intramedullary nailing 2% (12/770) 4 External fixation 1% (6/770) 5 Skeletal traction and hip spica casting 1% (8/770) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (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? Tested Concept QID: 1297 FIGURES: A Type & Select Correct Answer 1 Balanced skeletal traction 9% (118/1279) 2 External fixation 85% (1084/1279) 3 Intramedullary nail with trochanteric starting point 4% (54/1279) 4 Intramedullary nail with pirifomis starting point 1% (9/1279) 5 Plate fixation 0% (3/1279) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept
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