Femoral Shaft Fractures in Children

Description

• Femoral shaft fractures are defined as those >5 cm below the lesser trochanter, but above the distal metaphyseal (wider) portion of the lower femur.

• The location usually is specified as:– Proximal– Midshaft– Distal

Epidemiology

• Fractures of the femur are more common:– In areas of high population density or low

socioeconomic level– In children 0-3 and 12-16 years old– Represent 1.6% of all fractures in the pediatric

population.– Boys are more commonly affected at a ratio of 6:1.

MECHANISM OF INJURY

• Direct trauma: Motor vehicle accident, pedestrian injury, fall, and child abuse are causes.

• Indirect trauma: Rotational injury.• Pathologic fractures: Causes include

osteogenesis imperfecta, nonossifying fibroma, bone cysts, and tumors.

Femoral Shaft Fractures

Femoral Shaft FractureClassification

• Descriptive• Open versus closed• Level of fracture: proximal, middle, distal

third• Fracture pattern: transverse, spiral, oblique,

butterfly fragment• Comminution• Displacement• Angulation

Femoral Shaft FracturesClinical Features

• Obvious deformity• 50% have ligamentous instability of the knee• Neurovascular injuries rare in closed fractures• Fracture of Proximal 2/3

– Proximal fragment abducted, flexed, and externally rotated due to pull of gluteal and iliopsoas muscles of trochanters

• Fracture of Distal 1/3– Hyperextension of distal fragment due to pull of

gastrocnemius

Treatment Options

• Traction• Spica Casting• Pins & Plaster• External Fixation• Internal Fixation

– Plate/Screws– Flexible nails– Rigid Intramedullary rods - trochanteric vs.

lateral entry

Operative Indications

• Multiple trauma, including head trauma• Open fracture• Vascular injury• Pathologic fracture• Uncooperative patient• Body habitus not amenable to spica casting

Femoral Shaft Fractures: 0 - 6 Months

• Pavlik harness or a posterior splint is indicated.

• Traction and spica casting are rarely needed in this age group.

Femoral Shaft Fractures: 6 months - 5 years

• Immediate spica casting is nearly always the treatment of choice (>95%).

• Skeletal traction followed by spica casting may be needed if one is unable to maintain length and acceptable alignment; a traction pin is preferably placed proximal to the distal femoral physis.

• External fixation may be considered for multiple injuries or open fracture

Femoral Shaft Fractures: 6 months - 12 years

• Flexible intramedullary nails placed in a retrograde fashion are frequently used in this age group.

• External fixation or bridge plating may be considered for multiple injuries or open fracture.

• Some centers are using interlocked nails inserted through the greater trochanter (controversial).

• Spica casting may be used for the axially stable fractures in this age group.

Femoral Shaft Fractures: > 2 years

• Intramedullary fixation with either flexible or interlocked nails is the treatment of choice.

• Locked submuscular plates may be considered for supracondylar or subtrochanteric fractures.

• External fixation may be considered for multiple injuries or open fracture

Complication

Early :• Infection• Vascular injury• Compartment syndrome

Late :• Delayed union• Malunion • Nonunion