orthopaedics and trauma

1. Fractures of the Femoral Shaft
in the Pediatric Patient
Brent Norris, MD

2. 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

3. Treatment Goals - Restore
• Length
• Alignment
• Rotation

4. Treatment Goals - Avoid
• Osteonecrosis - disruption of blood supply
to femoral head
• Physeal injury- preserve future growth
potential (proximal and distal femoral
physes, trochanteric apophysis)

5. 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

6. 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

7. 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

8. Mechanism of Injury
• Low Energy
• High Energy
*predicts
behavior/treatment of the
fracture (Blount-1973,
Pollack-1994)

9. 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

10. 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

11. Radiographic Evaluation
• AP Pelvis
• AP/Lat femur
• Visualize hip & knee joints

12. 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

13. 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

14. 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

15. Decision Making
• Age
• Mechanism of injury
• Fracture pattern & location
• Associated Injuries
• Surgeon preference

16. 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

17. 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

18. 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)

19. 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

20. 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

21. Early “Sitting” Spica

23. 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

24. Surgical Options
• Plate & screw fixation
• External fixation
• Flexible nailing
• Rigid nailing

25. 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

26. ORIF Plate Fixation

27. 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

28. 11 yo male MVC
Pelvic fracture, ruptured bladder
External fixation

29. 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)

30. Open Femur Fracture
Principles
• IV antibiotics, tetanus
prophylaxis
• emergent irrigation &
debridement
• skeletal stabilization
• External fixation best
option with severe soft
tissue injury
• soft tissue coverage

31. Open Fractures

32. 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)

34. 12 yo male in ATV accident
Closed proximal third, oblique
Back at school 2 weeks
Walking at 8 weeks

35. Titanium Elastic Nailing - Results
Flynn et al. JPO Jan 2001
• 57/58 excellent or satisfactory
• No rotational malunions
• 6/58 – 1-2 cm LLD

36. 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

37. 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

38. 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

39. Why Not Use Rigid Nail?
Concern about AVN / osteonecrosis
of the femoral head

40. Anatomy
• Epiphyseal
blood supply
– Traverses the
piriformis
fossa
– Vulnerable
near greater
trochanter
Chung S. JBJS 58A, 1976.

41. Piriformis Fossa Entry Site
Raney E. JPO, 1993.
Thometz J, JBJS 1995.
Astion D, JBJS 1995

42. 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

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

44. 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.

45. 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 Results
Spica 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 Results
Spica 13 12 +8 30.5 d Malunion (4), >2.5 cm short (2)
Nail 12 14 +0 20.6 d Trochanteric Arrest (1)

46. 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 Results
Spica 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)

47. 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

48. 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

49. Percutaneous Bridge
Plating
Courtesy of E.M. Kanlic, MD, PhD

50. 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

51. Ends of nails can cause
soft tissue irritation

52. 12 yo 200 lb female – unstable fx
treated with flexible nails – healed
with 30 degree procurvatum malunion

53. 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

54. Trend Toward More
Invasive Treatment
• More high energy fractures
• Improved operative techniques
• Failed nonoperative treatment
• Simplifies patient care
• Psychological, social and financial reasons

55. 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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