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Updated: Oct 18 2021

Femoral Shaft Fractures - Pediatric

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  • summary
    • 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.
    • Diagnosis is made with plain radiographs of the femur. 
    • Treatment may be palvic harness, spica casting or operative depending on the fracture pattern and age of the patient.
  • 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
  • Etiology
    • 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
      • hemodynamic instability should raise suspecion for associated injuries
      • medical conditions and comorbidities
        • osteogenesis imperfecta
        • osteopenia secondary to neuromuscular disorders
        • benign or malignant bone tumors
  • 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
      • Pavlik harness
      • Early spica casting
      • 6 months - 5 years
      • 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 nail
      • 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
  • 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
  • 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
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