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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 under 10 years
      • a motor vehicle accident is the most common cause over 10 years
    • 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
    • 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
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 > 2 X bone diameter at that level) 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 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 up to 6 months
        • any fracture pattern
    • spica casting  
      • indications
        • children 0 - 5 years 
        • 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 weighing < 49kg (100 lbs)
    • submuscular bridge plate fixation 
      • indications
        • unstable fractures in children 5 or older and >49kg (100lbs)   
        • very proximal or very distal fractures
        • severe comminution
    • antegrade rigid intramedullary nail fixation 
      • indications
        • in patients >11 years 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
6m - 5 years
  • stable fracture pattern
  • early spica casting  
  • unstable fracture pattern
  • polytrauma/multiple fx/open fx
  • traction with delayed spica casting  
  • external fixator
5 - 11 years
  • length stable fx (transverse or oblique fx patterns)
  • patient weighs <  49kg (100 lbs)
  • flexible intramedullary nails   
  • length unstable fx (comminuted or spiral)
  • very proximal or distal fx
  • any weight
  • ORIF with submuscular bridge plating  
  • external fixation 

11 or greater years

 

  • patient weight <  49kg (100 lbs)
  • flexible intramedullary nails  
  • patient weight > 49kg (100 lbs)
  • antegrade rigid intramedullary nail fixation 
  • proximal or distal fracture
  • 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
        • decreased with applying smooth contours around popliteal fossa, limiting knee flexion to < 90° and avoiding excessive traction
        • Decreased by avoiding applying short leg cast first followed by traction on poplitea fossa 
        • monitored for by observing the child's neurovascular exam and level of comfort
    • 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.  the 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
 

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Questions (31)
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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

93%

(2235/2405)

2

Femoral nail with trochanteric starting point

2%

(59/2405)

3

Intramedullary flexible nails

1%

(18/2405)

4

Retrograde intramedullary nailing

1%

(24/2405)

5

External fixation with trochanteric fixation proximal

2%

(59/2405)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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%

(43/1766)

2

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

7%

(129/1766)

3

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

84%

(1487/1766)

4

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

3%

(45/1766)

5

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

3%

(51/1766)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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%

(4/609)

2

nonunion

4%

(24/609)

3

cosmetic deformity

3%

(19/609)

4

leg-length discrepancy

36%

(218/609)

5

loss of reduction

56%

(342/609)

ML 5

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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%

(63/2519)

2

Her height

1%

(22/2519)

3

Her weight

89%

(2236/2519)

4

Multiple extremity fractures

4%

(93/2519)

5

Open femur fracture

4%

(91/2519)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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

7%

(37/563)

2

Closed reduction and flexible intramedullary nailing

90%

(504/563)

3

Closed reduction and antegrade rigid femoral intramedullary nailing

1%

(8/563)

4

External fixation

1%

(4/563)

5

Skeletal traction and hip spica casting

1%

(5/563)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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%

(68/4160)

2

Figure B

91%

(3795/4160)

3

Figure C

2%

(89/4160)

4

Figure D

2%

(104/4160)

5

Figure E

2%

(81/4160)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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%

(89/982)

2

External fixation

86%

(841/982)

3

Intramedullary nail with trochanteric starting point

3%

(32/982)

4

Intramedullary nail with pirifomis starting point

1%

(8/982)

5

Plate fixation

0%

(2/982)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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%

(51/2652)

2

femoral head osteonecrosis

94%

(2498/2652)

3

femoral shaft non-union

1%

(15/2652)

4

nail breakage

0%

(7/2652)

5

proximal locking screw cutout

3%

(67/2652)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2
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