Fractures of the Femoral Shaft in the Pediatric Patient

Brent Norris, MD

Pediatric Femur Fractures

• 1.6 % all children's Fx’s• 28/100,000 child years (Holland)• 3:1 Male / Female ratio • Children >3 y.o.- highest incidence• Seasonal- highest summer

Treatment Goals - Restore

• Length• Alignment• Rotation

Treatment Goals - Avoid

• Osteonecrosis - disruption of blood supply to femoral head

• Physeal injury- preserve future growth potential (proximal and distal femoral physes, trochanteric apophysis)

Anatomy and Growth

• Proximal femoral physis- 30% of longitudinal growth

• Distal femoral physis- 70% of longitudinal growth

• Trochanteric apophysis- most of trochanteric growth appositional after age 8 years

Anatomy- Blood Supply Proximal Femoral Epiphysis

• Predominantly ascending cervical branch (B) of medial circumflex femoral artery

• Physis (D) - a barrier to intraosseous blood supply from femoral neck

Chung S. JBJS 58A, 1976

Pediatric Femur Fractures-Mechanism of Injury

• Rule out NAT in children <1year old• Falls- young children/toddlers• Struck by car- juvenile• Recreational sports/activities- adolescent• Motor vehicle crashes- all age groups

Mechanism of Injury

• Low Energy• High Energy

*predicts behavior/treatment of the fracture (Blount-1973, Pollack-1994)

Pediatric Femur Fractures- Associated Injuries

• Struck by car- triad of femur fracture, torso injuries, head injury

• Potential damage to physes of femur and proximal tibia

• Head Injury – spasticity can make traction and cast treatment difficult

• Abdominal injury – spica cast can constrict abdomen and limit ability to examine

Physical Exam

• Complete exam: head, chest, abdomen, and other skeletal segments

• Document distal neurologic and vascular function

• Palpate all bones• First Aid principles - Splint or traction

Radiographic Evaluation

• AP Pelvis• AP/Lat femur• Visualize hip & knee joints

Classification

• Open or closed• Location of fracture- subtrochanteric,

diaphyseal (proximal, mid, distal third), supracondylar

• Fracture pattern- transverse, spiral, oblique, comminuted, greenstick

• Amount of shortening• Angular deformity

7 Principles Dameron & Thompson JBJS 1959

• 1. Simplest treatment best• 2. Initial treatment permanent when

possible• 3. Perfect anatomic reduction not essential

for perfect function• 4. More potential growth= more

remodeling capability

Dameron & Thompson JBJS 1959

• 5. Restoration of alignment more important than fragment position

• 6. Overtreatment usually worse than undertreatment

• 7. Immobilize/splint injured limb before definitive treatment

Decision Making

• Age• Mechanism of injury• Fracture pattern & location• Associated Injuries• Surgeon preference

Traction Techniques

• Skin or skeletal• Avoid physes if place skeletal traction pins• Place pin perpendicular to shaft to avoid

varus/valgus angulation• Longitudinal in line traction for comfort

prior to definitive treatment• Split Russells traction (90-90) if awaiting

early healing prior to casting

Immediate or Early Spica Cast-Ideal Patient

• Less than 5 years old• Less than 100 lbs• Initial shortening not excessive• Isolated injury

• Note -Spica casts used for decades and can work for almost any pediatric femur fracture

Spica Cast Technique

• Appropriate padding• Cast liners may decrease skin problems• Traction to get 0-15 mm shortening• Mold laterally to prevent varus• Can wedge for unacceptable angulation at

1 week check (>10-20° varus/valgus, >15-30° procurvatum/recurvatum – age dependent)

Immediate Spica Cast

• Fiberglass lighter, easier to x-ray through• Often strong enough to obviate need for

connecting bar• See Kasser AAOS Instructional Course

Lectures Volume XLI, 1992

Immediate Spica Cast

• X-ray weekly for 3 weeks• Time in spica= age in years + 3 weeks up to

maximum 8 weeks• Wedge cast for malalignment• Rotational alignment important at initial

cast application

Early “Sitting” Spica

Femoral Remodeling after Fracture

• Will not correct significant rotational malunion

• Overgrowth 1-1.5 cm may occur, especially in younger children treated nonoperatively

• Angular deformity will remodel significantly in children <5 years old, less reliably in 5-10 year old, and is unlikely to be substantial in children >10 years old

Surgical Options

• Plate & screw fixation• External fixation• Flexible nailing• Rigid nailing

ORIF with Plates/Screws

• Advantages – rigid, technique familiar to most surgeons, allows early motion, favorable results reported in children with associated head injuries

• Disadvantages- large scar, possible refracture after plate removed, higher infection rate in some earlier series

ORIF Plate Fixation

External Fixation

• Advantages – can be applied rapidly, allows soft tissue injury management , early mobilization, avoid cast

• Disadvantages- pin site sepsis, pin site scarring, refracture, malunion

11 yo male MVC

Pelvic fracture, ruptured bladder

External fixation

External Fixator Tips

• Appropriate size half pin diameter• Proper pin placement relative to fracture for

biomechanical rigidity• Do not remove ex fix until see bridging

cortices (3 or 4 of 4)

Open Femur FracturePrinciples

• IV antibiotics, tetanus prophylaxis

• emergent irrigation & debridement

• skeletal stabilization• External fixation best

option with severe soft tissue injury

• soft tissue coverage

Open Fractures

Flexible Nailing

• Advantages – allows early mobilization without cast, cosmetic scars, avoids physes and blood supply to femoral head

• Disadvantages – later nail removal, ends may irritate soft tissues, may not be amenable to some fracture patterns (very proximal or distal, comminution)

12 yo male in ATV accident

Closed proximal third, oblique

Back at school 2 weeks

Walking at 8 weeks

Titanium Elastic Nailing - ResultsFlynn et al. JPO Jan 2001

• 57/58 excellent or satisfactory• No rotational malunions• 6/58 – 1-2 cm LLD

Titanium Elastic Nailing - Complications

Flynn et al. JPO Jan 2001• 5/9 proximal fx - > 5 degree angulation• 1 refracture after nail removal• 4/58 prominent nails – 1 premature

removal• 1 poor result – 11 yo, 15 mm short, 20

degrees varus

Flexible Nails

• Multiple studies from multiple institutions now report excellent outcomes with few complications

• If fracture pattern allows this is the preferred method of fixation for many

Rigid Nailing

• Advantages – rigid fixation, control rotation with interlocking screws

• Disadvantages -Risks injury to proximal femoral epiphysis (rare but possible devastating complication of osteonecrosis), may interfere with trochanteric growth

Why Not Use Rigid Nail?

Concern about AVN / osteonecrosis of the femoral head

Anatomy

• Epiphyseal blood supply– Traverses the

piriformis fossa– Vulnerable near

greater trochanter

Chung S. JBJS 58A, 1976.

Piriformis Fossa Entry Site

Raney E. JPO, 1993.

Thometz J, JBJS 1995.

Astion D, JBJS 1995

The Data –English Literature

• Estimated AVN Prevalence = 1-2%– 1996 POSNA membership survey– 15 cases identified– All following Rigid Reamed Nail – None following flexible nailing– 1 published case after trochanteric entry

• 6 Published Case Reports

• 13 Published Case Series

Case Series SummaryAUTHOR PUBLICATION # PTS AVG AGE IMPLANT TECHNIQUE MAL/DELAY AVN LLD>2cm PROX F/UKirby JPO 1981 13 14 (10) K R, PF 0 0 0 1 16Herndon JPO 1990 16 13 + 9 (11) K, AO R, PF 0 0 0 0 16Reeves JPO 1990 33 14 + 11 (11) K, AO R, PF 0 0 0 0 -- Ziv JOT 1984 8 8 + 4 (6) K R, PF 0 0 0 3 90Jaglan AAOS 1992 44 12 (5) -- -- 1 -- 0 0 21Maruenda Int Orthop 1993 29 11 +8 (7) K R, PF 0 0 0 1 80Timmerman JOT 1993 20 13 + 10 (10) K, AO, GF R, PF 0 0 0 0 27Beaty * JPO 1994 31 12 + 3 (10) RT R, L, PF 0 1 2 1 23Galpin JPO 1994 22 12 + 9 (11) GK, AO R, L, PF 0 0 1 5 33Garside POSNA 1994 17 9 + 6 (7) RT R, L, PF 0 0 0 4 27Buford * CORR 1998 54 12 (6) ? R, L, PF 0 2 0 -- 20Stans * JPO 1999 13 13 + 6 (11) R, L, GT 0 1 0 0 19Townsend CORR 2000 34 12 + 1 (10) RT R, L, GT 0 0 0 0 24TOTAL 334 12 1 4 3 15

Thometz et al., JPO 1995• CASE REPORT• 12 y.o. boy,s/p MVA• Pre-existing Asx

Acetabular Dysplasia + Coxa Valga

• Curved Küntscher Nail• PIRIFORMIS FOSSA• Pain @ 9 mo. post-op

ROH AVN @ 9 mo.• Osteotomies @ 15 mo.

IM Nailing vs. Non-op Treatment• Kirby et al., JPO 1981

– Traction / Spica vs. Closed IM Nailing

• Herndon et al., JPO 1989– Traction / Spica vs. Closed IM Nailing

# Pts. Avg Age Union Hosp stay ResultsSpica 24 13 +3 11.5 wk 28 d Malunion (7), >2.5 cm short (3)Nail 21 13 +9 10 wk 17 d

# Pts. Avg Age Hosp stay ResultsSpica 13 12 +8 30.5 d Malunion (4), >2.5 cm short (2)Nail 12 14 +0 20.6 d Trochanteric Arrest (1)

IM Nailing vs. Non-op Treatment

• Reeves et al., JPO 1990– Traction / Spica vs. Internal Fixation

• 30 Kuntscher Rods• 19 Plates

# Pts. Avg Age Hosp stay Cost ResultsSpica 41 12 +4 26 d 11,800 Delayed union (4), Malunion (5),

Growth disturbance (4), Psychotic Episodes (2)

Internal Fixation 49 14 +11 9 d 8,100 Transient Peroneal Palsy (1)

Trends in Pediatric Femur Fracture Management

• Much less frequent traction- casting• Immediate spica if <5 years old• Flexible nailing for patients 5 years old to

skeletal maturity• External fixation, plate fixation less

commonly used• Submuscular plating for certain fracture

patterns

Trends

• Trochanteric entry rigid nailing- new designs, large experience in some centers

• Limited/minimal incision plating techniques- bridge plate concept- popular in few trauma centers, useful for some fracture patterns/locations

• External fixation for severe soft tissue injuries in open fractures

Percutaneous Bridge Plating

Courtesy of E.M. Kanlic, MD, PhD

Complications of Femoral Shaft Fractures

• Limb length discrepancy – shortening most frequent

• Malunion (angular, rotational)• Nonunion rare• Osteonecrosis femoral head (rigid nailing)• Refracture (ex fix, plate removal)• Osteomyelitis (after operative treatment)• Traction pin injury to physes possible

Ends of nails can cause soft tissue irritation

12 yo 200 lb female – unstable fx treated with flexible nails – healed with 30 degree procurvatum malunion

13 yo male hit by car

Initially 2 retrograde TEN

1 became prominent

Healed 5 cm short

Lengthened over nail Healed with equal LL

Courtesy of

S.H.Sims, MD

Trend Toward More Invasive Treatment

• More high energy fractures • Improved operative techniques• Failed nonoperative treatment• Simplifies patient care• Psychological, social and financial reasons

Timmermann and Rab JOT 1993

• “Most children with fractures of the femur have a satisfactory outcome with any reasonable form of treatment.”

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