Femoral Shaft Fractures in Children

Original: M.L. Routt, Jr., M.D. Revised October, 2011: Andrew R. Evans, M.D.

Pediatric Femoral Shaft Fractures

One of the most common pediatric lower extremity fractures Most common pediatric fracture requiring hospital admission.

Treatment Options
Traction Spica Casting Pins & Plaster External Fixation Internal Fixation Plate/Screws Flexible nails Rigid Intramedullary rods - trochanteric vs. lateral entry

Pediatric Femoral Shaft Fractures

Treatment is often directed by the patients age 0-6 months 6 months - 5 years 5 - 11 years 11 years - skeletal maturity Other considerations Additional injuries, social situation, physician preference, etc.

Femoral Shaft Fractures: 0 - 6 Months

40% of femoral diaphyseal fractures in patients <1 year of age are non-accidental Child Abuse - approximately 15% of femoral shaft fractures in patients <36 months of age result from abuse >90% of pediatric femoral shaft fractures resulting from abuse occur in children <36 months of age

Femoral Shaft Fractures: 0 - 6 Months

AAOS Clinical Practice Guideline: All children < 36 months of age with a diaphyseal femur fracture must be evaluated for child abuse Complete History & Physical examination Consultation with Pediatrician, Family Practitioner, and/or Child Abuse Team Skeletal survey if warranted

Femoral Shaft Fractures: 0 - 6 Months

Pavlik harness

Stable union typically achieved within 5 weeks

Spica casting Higher risk of skin complications than Pavlik

Waterproof cast liners improve sanitation

Spica casting with incorporated distal femoral traction pin

May decrease incidence of unacceptable shortening and frontal plane malalignment

Diaphyseal Femur Fractures:

Femoral Shaft Fractures: 6 months - 5 years

Early spica casting (90/90)

<2cm shortening

Enhanced ease of care Shorter hospital stay No defined optimal weight range Spica casting in ED versus OR yield similar reduction quality and complication rates

Traction with delayed spica casting Skin traction typically ineffective; skeletal traction often required

Femoral Shaft Fractures: 6 months - 5 years

Diaphyseal Femur Fractures: > 2cm shortening

Spica casting

Insufficient evidence to recommend for/against (AAOS Clinical PracticeGuideline) Mode of treatment may be altered if deemed necessary

External fixation

Lower incidence of malunion compared to spica casting

Flexible IM nailing may be considered for the oldest, most

Femoral Shaft Fractures: 6 months - 5 years

Insufficient evidence exists to recommend any specific degree of angulation, rotation, or shortening that is unacceptable (AAOS Clinical Practice Guideline) Traditionally: Varus/valgus deformity more poorly tolerated than flexion/extention deformity Up to 30 of rotational malunion can be tolerated Remodelling occurs to a greater extent in younger children with more growth potential Overgrowth is a biologic response to fracture in this age group but is unpredictable

Femoral Shaft Fractures: 5 - 11 years

Skeletal Traction Typically used to precede definitive treatment particularly in severely traumatized patients

Spica casting Poorly tolerated, Higher risk of malunion

Femoral Shaft Fractures: 5 - 11 years

External Fixation Lower incidence of malunion than spica casting Ease of hardware removal compared to plates or nails Risk of re-fracture, pin site infection, scarring/stiffness of IT band Excellent mode of provisional fixation

Femoral Shaft Fractures: 5 - 11 years

Flexible (Elastic) Intramedullary Nails Preferred method for treatment of most femoral disphyseal fractures in this age group Titanium or stainless steel (Enders) Antegrade or retrograde (more common) insertion Outcomes best when used to treat stable fracture patterns Shorter hospital stay Fewer adverse events More rapid return to school Most common complication is irritation at distal insertion sites Increased risk of poor outcome in children weighing >108 lbs (49kg)

Femoral Shaft Fractures: 5 - 11 years

Sub-muscular plating Compression versus bridging plate techniques Open reduction versus minimally invasive plate osteosynthesis (MIPO) May address stable or unstable fracture patterns effectively Indications for plate removal remain controversial

Femoral Shaft Fractures: 11 years - Skeletal Maturity

External Fixation Useful to achieve provisional fixation of femoral fractures in severely injured patients or open fractures May be used for definitive treatment of subtrochanteric or distal metadiaphyseal fractures that are less amenable to plate or nail fixation Avoids direct fracture exposure, minimizes blood loss, minimizes risk of physeal injury More frequent complications include delayed union and refracture after device removal

Femoral Shaft Fractures: 11 years - Skeletal Maturity

Flexible intramedullary nails Outcomes optimized when use is limited to stable fracture patterns Higher risk of complications in patients >11 years of age, >108 lbs (49kg), and unstable fracture patterns Commonly reported complications: knee pain at insertion site, nail prominence, nail migration, fracture shortening/malunion, delayed union

Femoral Shaft Fractures: 11 years - Skeletal Maturity

Sub-muscular plating Compression versus bridging plate techniques Open reduction versus minimally invasive plate osteosynthesis (MIPO) May address stable or unstable fracture patterns effectively Accurate and stable reductions are achievable; malunions uncommon

Femoral Shaft Fractures: 11 years - Skeletal Maturity

Submuscular plating: Open reduction with soft-tissue stripping fracture exposure may increase risk of non-union Risk of re-fracture if plate is removed

Rigid intramedullary nailing - greater trochanteric entry femoral nail Well suited for unstable fracture patterns Patients >108lbs (49kg) who are not candidates for flexible IM nailing Piriformis or near-piriformis entry nailing is NOT a treatment option Risk of injury to the lateral ascending cervical branches of the medial femoral circumflex vessel in the piriformis fossa Increased risk of femoral head osteonecrosis (4%) Risk of coxa vara due to trochanteric apophyseal growth arrest Permits rapid mobilization

Femoral Shaft Fractures: 11 years - Skeletal Maturity

Femoral Shaft Fractures: 11 years - Skeletal Maturity

Femoral head osteonecrosis

Femoral Shaft Fractures: 11 years - Skeletal Maturity

Rigid intramedullary nailing- lateral entry femoral nail Similar indications to trochanteric entry nails Designed to avoid injury to circumflex vessels and trochanteric apophysis

Pediatric Femoral Shaft Fractures

Unable to recommend for/against removal of surgical implants from asymptomatic patients with healed diaphyseal femur fractures (AAOS Clinical Practice Guideline) Risks include refracture, hematoma, infection, scarring, etc. Regional anesthesia is an option for perioperative care (Hematoma and/or Femoral Nerve Block) - AAOS Clinical Practice Guideline Reduced narcotic administrated demonstrated with hematoma block

References
Aksahin E, et. al. Immediate Incorporated Hip Spica Casting in Pediatric Femoral Fractures: Comparison of Efficacy Between Normal and High Risk Groups. Journal of Pediatric Orthopaedics 2009; 29(1): 39-43. Anglen JO, Choi L. Treatment Options in Pediatric Femoral Shaft Fractures. Journal of Orthopaedic Trauma 2005; 19(10): 724-733. Flynn HM, Luedtke LM, Ganley TJ, Dawson J, Davidson RS, Dormans JP, Ecker ML, Gregg JR, Horn BD, Drummond DS. Comparison of Titanium Elastic Nails With Traction and a Spica Cast to Treat Femoral Fractures in Children. J Bone & Joint Surg Am 2004; 86: 770-777. Flynn JM, Schwend RM. Management of Pediatric Femoral Fractures. JAAOS 2004; 12(5): 347-359. Garner MR, Bhat SB, Khujanazarov I, Flynn JM, Spiegel D. Fixation of Length-Stable Femoral Shaft Fractures in Heavier Children. Journal of Pediatric Orthopaedics 2011; 31(1): 11-16. Gautier E, Ganz K, Krugel N, Gill T, Ganz R. Anatomy of the Medial Femoral Circumflex Artery and Its Surgical Implications. J Bone & Joint Surg Br 2000; 82(5): 679-683. Hosalkar HS, Pandya NK, Cho RH, Glaser DA, Moor MA, Herman MJ. Intramedullary Nailing of Pediatric Femoral Shaft Fractures. JAAOS 2011; 19(8): 472-481. Mansour AA, Wilmoth JC, Mansour AS, Lovejoy SA, Mencio GA, Martus JE. Immediate Spica Casting of Pediatric Femoral Fractures in the Operating Room Versus the Emergency Department: Comparison of Reduction, Complications, and Hospital Charges. Journal of Pediatric Orthopaedics 2010; 30(8): 813-817. Kocher MS, Sink EL, Blasier RD, Luhmann SJ, Mehlman CT, Scher DM, Matheney T, Sanders JO, Watters WC, Goldberg MJ, Keith MW, Haralson RH, Turkelson CM, Wies JL, Sluka P, Hitchcock K. AAOS Clinical Practice Guideline Summary: Treatment of Pediatric Diaphyseal Femur Fractures. JAAOS 2009; 17: 718-725. Poolman RW, Kocher MS, Bhandari M. Pediatric Femoral Fractures: A Systematic Review of 2422 Cases. Journal of Orthopaedic Trauma 2006; 20(9): 648-654. Sagan ML, Datta JC, Olney BW, Lansford TJ, McIff TE. Residual Deformity After Treatment of Pediatric Femur Fractures With Flexible Titanium Nails. Journal of Pediatric Orthopaedics 2010; 30(7): 638-643.

References
Sink EL, Faro F, Polousky J, Flynn K, Gralla J. Decreased Complications of Pediatric Femur Fractures With a Change in Management. Journal of Pediatric Orthopaedics 2010; 30(7): 633-637. Wright JG. The Treatment of Femoral Shaft Fractures in Children: A Systematic Overview and Critical Appraisal of the Literature. Canadian Journal of Surgery 2000; 43(3): 180-189.

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