FEMORAL SHAFT FRACTURES

Transcription

27
Femoral Shaft Fractures
John M. Flynn and David L. Skaggs
•• Anatomy 987
•• Mechanism
of Injury •• Complications 1015
988
•• Diagnosis 988
•• X-Ray Findings 989
•• Classification 989
•• Treatment 989
Treatment Variation with Age 989
Treatment Variation with Fracture Pattern 992
•• Treatment Options 992
Pavlik Harness 992
Spica Cast Treatment 993
Flexible Intramedullary Nail Fixation 998
External Fixation 1004
Rigid Intramedullary Rod Fixation 1006
Plate Fixation 1010
•• Author’s Preferred Treatment 1014
Femur fractures are common.60,122 When subtrochanteric and
supracondylar fractures are included, the femoral shaft represents about 1.6% of all bony injuries in children. Fractures
are more common in boys (2.6:1), and occur in an interesting bimodal distribution with a peak during the toddler years
(usually from simple falls) and then again in early adolescence
(usually from higher-energy injury).62,77,86,112 A recent Swedish
incidence study78 also showed a seasonal bimodal variation,
with the peak in March and in August.
Although pediatric femoral shaft fractures create substantial
short-term disability, with attention to detail and modern techniques, these major injuries can generally be treated successfully with few long-term sequelae. Over the past 20 years, there
has been a dramatic and sustained trend toward the operative
stabilization of femoral shaft fractures in school-aged children
using flexible intramedullary nails, external fixation, locked
Leg Length Discrepancy 1015
Angular Deformity 1015
Rotational Deformity 1015
Delayed Union 1017
Nonunion 1017
Muscle Weakness 1017
Infection 1018
Neurovascular Injury 1018
Compartment Syndrome 1018
•• Special Fractures 1018
Subtrochanteric Fractures 1018
Supracondylar Fractures 1019
Open Femoral Fractures 1019
Patients with Metabolic or Neuromuscular
Disorders 1022
Floating Knee Injuries 1022
Multiple-System Trauma Patient 1023
intramedullary nails, and more recently, submuscular plate
fixation. These advances have decreased the substantial early
disability for the children as well as the family’s burden of care
during the recovery period.
Anatomy
of
Through remodeling during childhood, a child’s bone changes
from primarily weak woven bone to stronger lamellar bone.180
Strength also is increased by a change in geometry (Fig. 27-1).
The increasing diameter and area of bone result in a markedly increased area moment of inertia, leading to an increase
in strength. This progressive increase in bone strength helps
explain the bimodal distribution of femoral fractures. In early
childhood, the femur is relatively weak and breaks under
load conditions reached in normal play. In adolescence,
987
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988 Section four Lower Extremity
Area (mm2)
Age (y)
Figure 27-1 The shaded area represents cortical thickness by agegroup. This rapid increase in cortical thickness may contribute to
the diminishing incidence of femoral fractures during late childhood.
(Redrawn from Netter FH. The Ciba collection of medical illustrations.
Musculoskeletal System. I. Anatomy, Physiology, and Metabolic Disorders. Vol 8. Summit, NJ: Ciba-Geigy; 1987, with permission.)
high-velocity trauma is required to reach the stresses necessary for fracture.
Mechanism of Injury
Shaft Fractures
of
Femoral
The etiology of femoral fractures in children varies with the age
of the child. Before walking age, up to 80% of femoral fractures
may be caused by abuse.11,18,69,184 In a study of over 5,000 children at a trauma center, Coffey et al.37 found that abuse was
the cause of only 1% of lower extremity fractures in children
older than 18 months, but 67% of lower extremity fractures in
children younger than 18 months.
Baldwin et al.8 found three primary risk factors for abuse
in young children presenting with a femur fracture: A history
suspicious for abuse, physical or radiographic evidence of prior
injury, and age under 18 months. Children with no risk factors had only a 4% chance of being a victim of abuse, whereas
children with all three risk factors had a 92% chance that their
femur fractures with result of abuse.
Older children are unlikely to have a femoral shaft fracture
caused by abuse, because their bone is sufficiently strong to tolerate forceful blows, or is able to resist torque without fracture.
In older children, femoral fractures are most likely to be caused
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by high-energy injuries; motor vehicle accidents account for
over 90% of femur fractures in this age group.42,77,121 Pathologic
femur fractures are relatively rare in children, but may occur
because of generalized osteopenia in infants or young children
with osteogenesis imperfecta. Osteogenesis imperfecta should
be considered when a young child, with no history suggestive
of abuse or significant trauma, presents with a femoral shaft
fracture.111 Radiologic evaluation is often insufficient to diagnose osteogenesis imperfecta; skin biopsy, collagen analysis,
and bone biopsy may be required to make a definitive diagnosis. Generalized osteopenia also may accompany neurologic
diseases, such as cerebral palsy or myelomeningocele, leading to fracture with minor trauma in osteopenic bone.62,105,111
Pathologic fractures may occur in patients with neoplasms,
most often benign lesions such as nonossifying fibroma, aneurysmal bone cyst, unicameral cyst, or eosinophilic granuloma.
Although pathologic femur fractures are rare in children, it is
essential that the orthopedist and radiologists study the initial
injury films closely for the subtle signs of primary lesions predisposing to fracture, particularly in cases of low-energy injury
from running or tripping. Radiographic signs of a pathologic
fracture may include mixed lytic–blastic areas disrupting trabecular architecture, break in the cortex and periosteal reaction
in malignant lesions such as osteosarcoma, or better-defined
sclerotic borders with an intact cortex seen in benign lesions
such as nonossifying fibroma (Fig. 27-2).
Stress fractures may occur in any location in the femoral
shaft.28,101,137 In this era of high-intensity, year-round youth
sports, orthopedists are more commonly encountering adolescents with femoral stress fractures from running, soccer, and
basketball.23 Although uncommon (4% of all stress fractures in
children), femoral shaft or femoral neck stress fractures should
be considered in a child with thigh pain because an unrecognized stress fracture may progress to a displaced femoral
fracture. A high index of suspicion is important, because even
nontraditional sports can lead to stress fractures with extreme
overuse; a recent report of bilateral femoral stress fractures were
reported in a Rollerblade enthusiast.201
Diagnosis
of
The diagnosis of pediatric femoral shaft fractures is usually not
subtle: There is a clear mechanism of injury, a deformity and swelling of the thigh, and obvious localized pain. The diagnosis is more
difficult in patients with multiple trauma or head injury and in
nonambulatory, severely disabled children. A physical examination usually is sufficient to document the presence of a femur
fracture. In patients lacking sensation (myelomeningocele), the
swelling and redness caused by a fracture may mimic infection.
In the setting of a femur fracture, a comprehensive physical
examination should be performed looking for other sites of injury.
Hypotension rarely results from an isolated femoral fracture.
Waddell’s triad of femoral fracture, intra-abdominal or intrathoracic injury, and head injury are associated with high-velocity
automobile injuries. Multiple trauma may necessitate rapid stabilization of femoral shaft fractures121,164 to facilitate overall care. This
is particularly true with head injury and vascular disruption.
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Chapter 27 Femoral Shaft Fractures 989
Figure 27-2 A: Femoral fracture
through a poorly demarcated, mixed,
osteoblastic, osteolytic lesion—an osteosarcoma. B: Sclerotic borders of this
lesion in the distal femur are typical of
a pathologic fracture through a nonossifying fibroma.
A
The hemodynamic significance of femoral fracture has been
studied by two groups.35,124 Hematocrit levels below 30% rarely
occur without multisystem injury. A declining hematocrit
should not be attributed to closed femoral fracture until other
sources of blood loss have been eliminated.35,124
X-Ray Findings
of
Radiographic evaluation should include the entire femur,
including the hip and knee, because injury of the adjacent
joints is common. An anteroposterior (AP) pelvis x-ray is a
valuable supplement to standard femoral shaft views, because
there may be associated intertrochanteric fractures of the hip,
fractures of the femoral neck, or physeal injuries of the proximal femur.14,30 Distal femoral fractures may be associated with
physeal injury about the knee, knee ligament injury, meniscal
tears,204 and tibial fractures.116
Plain x-rays generally are sufficient for making the diagnosis. In rare circumstances, bone scanning and magnetic resonance imaging (MRI) may be helpful in the diagnosis of small
buckle fractures in limping children or stress fractures in athletes. The orthopedist should carefully evaluate radiographs for
comminution or nondisplaced “butterfly” fragments, second
fractures, joint dislocations, and pathologic, as these findings
can substantially alter the treatment plan.
Classification
of
Femoral fractures are classified as (a) transverse, spiral, or short
oblique; (b) comminuted or noncomminuted; and (c) open
or closed. Open fractures are classified according to Gustilo’s
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B
system.81 The presence or absence of vascular and neurologic
injury is documented and is part of the description of the fracture. The most common femoral fracture in children (over
50%) is a simple transverse, closed, noncomminuted injury.
The level of the fracture (Fig. 27-3) leads to characteristic
displacement of the fragments based on the attached muscles.
With subtrochanteric fractures, the proximal fragment lies in
abduction, flexion, and external rotation. The pull of the gastrocnemius on the distal fragment in a supracondylar fracture
produces an extension deformity (posterior angulation of the
femoral shaft), which may make the femur difficult to align.
Treatment
of
Treatment of femoral shaft fractures in children depends on two
primary considerations: Age (Table 27-1) and fracture pattern.
Secondary considerations, especially in operative cases, include
the child’s weight, associated injuries, and mechanism of injury.
Economic concerns,40,59,153,156,195 the family’s ability to care for a
child in a spica cast or external fixator, and the advantages and
disadvantages of any operative procedure also are important
factors. Kocher et al.110 summarized the current evidence for
pediatric femur fracture treatment in a clinical practice guideline summary.
Treatment Variation with Age for Femoral
Shaft Fractures
Infants
Femoral shaft fractures in infants are usually stable because
their periosteum is thick. In fractures occurring in infancy,
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Table 27-1
A
B
C
Age
Treatments
Birth to 24 mos
Pavlik harness (newborn to 6 mos)
Early spica cast
Traction → spica cast (very rare)
24 mos–5 y
Early spica cast
Traction → spica cast
External fixation (rare)
Flexible intramedullary nails (rare)
6–11 y
Flexible intramedullary nails
Traction → spica cast
Submuscular plate
External fixation
12 y to maturity
Trochanteric entry intramedullary rod
Flexible intramedullary nails
Submuscular plate
External fixation (rare)
D
E
Figure 27-3 The relationship of fracture level and position of the
proximal fragment. A: In the resting unfractured state, the position
of the femur is relatively neutral because of balanced muscle pull.
B: In proximal shaft fractures the proximal fragment assumes a position of flexion (iliopsoas), abduction (abductor muscle group), and
lateral rotation (short external rotators). C: In midshaft fractures the
effect is less extreme because there is compensation by the adductors and extensor attachments on the proximal fragment. D: Distal shaft fractures produce little alteration in the proximal fragment
position because most muscles are attached to the same fragment,
providing balance. E: Supracondylar fractures often assume a position of hyperextension of the distal fragment because of the pull of
the gastrocnemius.
management should include evaluation for underlying metabolic bone abnormality or abuse. Once these have been ruled
out, most infants with a proximal or midshaft femoral fracture
are comfortably and successfully treated with simple splinting
to provide some stability and comfort, with a Pavlik harness
to improve the resting position of the fracture. For the rare
unstable fracture, the Pavlik harness may not offer sufficient
stabilization. Morris et al.149 reported a group of eight birthrelated femoral fractures in 55,296 live births. Twin pregnancies, breech presentation, and prematurity were associated with
birth-related femur fractures. The typical fracture is a spiral
fracture of the proximal femur with flexion of the proximal
fragment. With thick periosteum, and remarkable remodeling
potential, newborns rarely need a manipulative reduction of
their fracture, nor rigid external immobilization. For femoral
fractures with excessive shortening (>1 to 2 cm) or angulation
(>30 degrees), spica casting may be used. Traction rarely is necessary in this age group.
Preschool Children
In children 6 months to 5 years of age, early spica casting
(Fig. 27-4) is the treatment of choice for isolated femur fractures with less than 2 cm of initial shortening (Fig. 27-5). In
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reatment Options for Isolated
T
Femoral Shaft Fractures in
Children and Adolescents
Treatment choices are influenced by fracture pattern, the child’s weight, the
presence of other injuries (head, chest, abdominal, etc.) and associated soft
tissue trauma.
low-energy fractures, the “walking spica” is ideal (Fig. 27-6).
Femur fractures with more than 2 cm of initial shortening or
marked instability and fractures that cannot be reduced with
early spica casting require 3 to 10 days of skin or skeletal traction. Internal or external fixation is rarely needed in children
less than 5 years of age. In rare circumstances, external fixation can be used for children with open fractures or multiple
trauma. Intramedullary fixation is used in children with metabolic bone disease that predisposes to fracture or after multiple
fractures, such as in osteogenesis imperfecta, or following multitrauma. Flexible nailing can be used in the normal-sized preschool child20 but is rarely necessary. Larger children (in whom
reduction cannot be maintained with a spica cast) occasionally
may benefit from flexible intramedullary nailing, traction, or in
rare cases, submuscular plating.
Children 5 to 11 Years of Age
In children 5 to 11 years of age, many different methods can be
used successfully, depending on the fracture type, patient characteristics, and surgeon skill and experience.60 For the rare, minimally displaced fracture, early spica casting usually produces
satisfactory results, although cast wedging or a cast change may
be necessary to avoid excessive shortening and angulation. In
children with unstable, comminuted fractures, traction may be
necessary prior to cast application. Although traction and casting is still a very acceptable and successful method of managing femur fractures in young school-age children, the cost and
the social problems related to school-age children in casts have
resulted in a strong trend toward fracture fixation. Spica cast
management is generally not used for children with multiple
trauma, head injury, vascular compromise, floating knee injuries, significant skin problems, or multiple fractures. Flexible
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A
B
C
D
Figure 27-4 A: This 7-month old sustained a low-energy spiral femoral shaft fracture. B: Treatment
was in a spica cast. C, D: Excellent healing with abundant callus at only 4 weeks after injury.
intramedullary nails are the predominant treatment for femur
fractures in 5- to11-year olds, although submuscular plating and
external fixation have their place, especially in length-unstable
fractures, or in those difficult to manage fractures in the proximal
and distal third of the femoral shaft.
Age 11 to Skeletal Maturity
Trochanteric entry, locked intramedullary nailing is now the
primary mode of treatment for femur fractures in the preadolescent and adolescent age groups. Several studies designed
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to refine the indications for flexible intramedullary nailing
have concluded that although most results are excellent or
satisfactory in children older than 11, complications rise significantly when this popular technique is used for bigger and
older children. In an international multicenter, retrospective
study, Moroz et al.148 found a statistically significant relationship between age and outcome, with children older than 11
years or heavier than 49 kg faring worse. Sink et al.187 found
a much higher rate of complications in length-unstable
fractures. Fortunately, surgeons can now select from several
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A, B
C
Figure 27-5 A: This 2-year-old sustained a low-energy spiral femoral shaft fracture, ideal for walking
spica treatment. B: Immediately after reduction, note the lateral mold at the fracture site. C: Six weeks
after injury, there is anatomic alignment, minimal shortening, and good callus formation.
different trochanteric entry nails that allow a relatively safe,
lateral entry point, with the stability of proximal and distal
locking. With this new information and technology, locked
intramedullary nailing is used commonly for obese children of
ages 10 to 12, and most femoral shaft fractures in children of
ages 13 to skeletal maturity.
Treatment Variation with Fracture Pattern
for Femoral Shaft Fractures
In addition to age, the treating surgeon should consider fracture
pattern, especially when choosing implant. Elastic nailing is
ideal for the vast majority of length-stable midshaft femur fractures in children between the ages of 5 and 11 years old. For
length-unstable fractures, the risk of shortening and malunion
increases substantially when elastic nailing is used.186 Lengthunstable fractures are best treated with locked trochanteric
entry nailing in older children, external fixation in younger
children, or submuscular plating in either of these age cohorts.
Treatment Options
Shaft Fractures
for
Femoral
Pavlik Harness for Femoral Shaft Fractures
Figure 27-6 A 4-year old with a minimally displaced midshaft
femur fracture treated with a walking spica cast, shown here
4 weeks after injury.
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Stannard et al.194 popularized the use of the Pavlik harness for
femur fractures in infants. This treatment is ideal for a proximal or midshaft femoral fracture that occurs as a birth-related
injury. Reduction can be aided by a loosely wrapping cotton
cast padding around the thigh if greater stability is needed.
In a newborn infant in whom a femur fracture is noted in
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the intensive care unit or nursery, the femur is immobilized
with simple padding or a soft splint. For a stable fracture, this
approach may be sufficient and will allow intravenous access to
the feet if needed. The Pavlik harness can be applied with the
hip in moderate flexion and abduction. This often helps align the
distal fragment with the proximal fragment (Fig. 27-7). Evaluation of angulation in the coronal plane (varus–valgus) is difficult
because of hyperflexion. Stannard et al.194 reported acceptable
alignment in all patients with less than 1 cm of shortening.
Morris et al.149 showed that all treatments, including traction,
spica cast, and Pavlik harness, are effective and resulted in satisfactory outcome in all patients regardless of treatment.
Podeszwa et al.162 reported infants treated with a Pavlik had
higher pain scores when compared to a immediate spica cast;
however, none of the Pavlik patients had skin problems but
one-third of the spica patients did.
Spica Cast Treatment for Femoral
Shaft Fractures
Spica casting97,192 is usually the best treatment option for isolated femoral shaft fractures in children under 6 years of age,
A
unless there is (a) shortening of more than 2 cm, (b) massive
swelling of the thigh, or (c) an associated injury that precludes
cast treatment. Several centers have adopted spica application
in the emergency department as their standard treatment for
infants and toddlers. Mansour et al.128 compared spica cast
placement in the emergency department versus the operating room, and concluded that the outcome and complications were similar, but the children treated in the operating
room had longer hospital stays and significantly higher hospital charges. Cassinelli et al.33 treated 145 femur fractures,
all in children younger than age 7, with immediate spica
cast application in the emergency department. All children
younger than 2 years of age, and 86.5% of children of ages 2
to 5 years old, met acceptable alignment parameters on final
radiographs. Rereduction in the operating room was needed
in 11 patients. The investigators concluded that initial shortening was the only independent risk factor associated with
lost reduction.
The advantages of a spica cast include low cost, excellent safety profile, and a very high rate of good results, with
acceptable leg length equality, healing time, and motion.54,96
B
C
Figure 27-7 A: A newborn baby presents with a classic proximal femoral birth fracture, in flexion and abduction. The baby
was placed in the Pavlik harness B: A follow-up check 2 weeks
after injury shows excellent alignment and early callous. C: A
follow-up at 4 weeks shows a healed fracture. The Pavlik harness was removed. D: Follow-up 7 weeks after injury shows
the dramatic early remodeling that is typical of these fractures.
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D
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Table 27-2
Acceptable Angulation
Varus/Valgus
(degrees)
Anterior/Posterior
(degrees)
Shortening (mm)
Birth to 2 y
30
30
15
2–5 y
15
20
20
6–10 y
10
15
15
5
10
10
Age
11 y to maturity
Hughes et al.90 evaluated 23 children ranging in age from
2 to 10 years who had femur fractures treated with early spica
casting to determine the impact of treatment on the patients
and their families. The greatest problems encountered by the
family in caring for a child in a spica cast were transportation, cast intolerance by the child, and hygiene. In a similar
study, Kocher109 used a validated questionnaire for assessing
the impact of medical conditions on families demonstrated that
for family, having a child in a spica cast is similar to having a
child on renal dialysis. They found that the impact was greatest for children older than 5 years, and when both parents are
working. Such data should inform the decisions of orthopedic surgeons and families who are trying to choose among the
many options for young school-age children.
Illgen et al.,95 in a series of 114 isolated femoral fractures in
children under 6 years of age, found that 90-degree/90-degree
spica casting was successful in 86% without cast change or
wedging, based on tolerance of shortening less than 1.5 cm and
angulation less than 10 degrees. Similar excellent results have
been reported by Czertak and Hennrikus41 using the 90/90
spica cast.
Thompson et al.197 described the telescope test in which
patients were examined with fluoroscopy at the time of reduction and casting. If more than 3 cm of shortening could be
demonstrated with gentle axial compression, traction was
used rather than immediate spica casting. By using the telescope test, these researchers decreased unacceptable results
(>2.5 cm of shortening) from 18% to 5%. Shortening is
acceptable, but should not exceed 2 cm. This is best measured
on a lateral x-ray taken through the cast. If follow-up x-rays
reveal significant varus (>10 degrees) or anterior angulation
(>30 degrees), the cast may be wedged. However, Weiss
et al.211 noted that wedging of 90/90 spica casts can cause
peroneal nerve palsy, especially during correction of valgus
angulation (a problem that rarely occurs). For unacceptable
position, the fracture can be manipulated and a new cast
applied, or the cast can be removed and the patient placed in
traction to regain or maintain length. Angular deformity of up
to 15 degrees in the coronal plane and up to 30 degrees in the
sagittal plane may be acceptable, depending on the patient’s
age (Table 27-2). Finally, if shortening exceeds 2 cm, traction
or an external fixator can be used (Fig. 27-8).
The position of the hips and knees in the spica cast is controversial. Some centers prefer a spica cast with the hip and knee
flexed 90 degrees each. Studies have shown that the results
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from the sitting spica cast are good.133,143 The child is placed
in a sitting position with the legs abducted about 30 degrees
on either side. The synthetic material used for the cast gives it
sufficient strength so that no bar is required between the legs.
This not only allows the child to be carried on the parent’s hip
but also aids in toiletry needs, making bedpans unnecessary.
Also, a child who can sit upright during the day can attend
school in a wheelchair. More recently, with reports about compartment syndrome of the leg after using the 90/90 spica cast,
several centers have moved to a cast in which the hip and knee
are more extended (about 45 degrees each) and the bottom of
the foot cut out to prevent excessive shortening.134 Varying the
amounts of hip and knee flexion in the spica cast based on the
position of the fracture also has been recommended: The more
proximal the fracture, the more the hip should be flexed.192
Figure 27-8 A proximal spiral femur fracture, which failed treatment with pins and plaster, and was salvaged with an external fixator.
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Recently, there has been a resurgence of interest in the “walking spica cast” (Fig. 27-6). Epps et al.51 reported on immediate
single leg spica cast for pediatric femoral diaphyseal fracture. In
a series of 45 children, 90% of the children pulled to stand and
62% of the children walked independently by the end of treatment. Fifty percent of patients were able to return to school
or day care while in the cast. Only two children had unacceptable shortening, and two required repeat reduction. Flynn
et al.57 performed a prospective study of low-energy femoral
shaft fractures in young children, comparing a walking spica
cast to a traditional spica cast. Although the outcome with
the two treatment method was similar, the walking spica cast
resulted in substantially lower burden of care for the family.
Children with a walking spica are more likely to have their cast
wedged in clinic to correct early loss of reduction. Practitioners
of the single leg, or walking spica, have learned to use the tech-
nique only on toddlers with very stable, low-energy fractures.
The cast must be extensively reinforced at the hip. With the hip
and knee much more extended, the single leg spica not only
improves function and ease of care, but also avoids a technique
that has been associated with compartment syndrome in several children (see below).113,151 Increasingly, the walking spica
is considered the best treatment for low-energy femur fractures
in toddlers.57,117
Spica Cast Application: Technique
The cast is applied in the operating room or, in some centers,
the sedation unit or Emergency Department.128 For the sitting
spica cast technique, a long leg cast is placed with the knee and
ankle flexed at 90 degrees (Fig. 27-9B). Knee flexion greater
than 60 degrees improved maintenance of length and reduction.95 However, if one applies excessive traction to maintain
A
B
Figure 27-9 Application of a 90-degree/90-degree spica cast.
A: Generous padding is applied over the foot, and a pad is placed
on the popliteal fossa to prevent injury to the peroneal nerve and
popliteal vessels. B: A long leg cast is applied with the knee flexed
90 degrees. C: A mold is placed over the apex of the fracture, generally correcting a varus deformity into slight valgus.
C
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(continues)
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D
Figure 27-9 (continued) D: Using a standard spica table, a 1½
spica cast is applied with the hip flexed 90 degrees and abducted
30 degrees.
length (Fig. 27-10), the risk of compartment syndrome is unacceptably high. Less traction, less knee flexion, and accepting
slightly more shortening is a reasonable compromise. Extra
padding, or a felt pad, is placed in the area of the popliteal
fossa. The knee should not be flexed after the padding is placed
because the lump of material in the popliteal fossa may create vascular obstruction (Fig. 27-9A). Because most diaphyseal fractures lose reduction into varus angulation while in a
spica cast, a valgus mold at the fracture site is recommended
(Fig. 27-9C). The patient is then placed on a spica table, supporting the weight of the legs with manual traction, and the
remainder of the cast is applied with the hips in 90 degrees of
Figure 27-10 The dangers of pulling upward on the calf when
applying a spica: This upward pull, which is used to reduce the fracture, can be dangerous, because it puts pressure on the gastrocnemius muscle and the other posterior leg structures, such as the
femoral artery and femoral vein. (Reprinted from Skaggs D, Flynn J.
Trauma about the pelvis/hip/femur. Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins;
2006:105.)
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flexion and 30 degrees of abduction, holding the fracture out to
length (Fig. 27-9D). It is mandatory to avoid excessive traction
because compartment syndromes and skin sloughs have been
reported. The leg should be placed in 15 degrees of external
rotation to align the distal fragment with the external rotation
of the proximal fragment. After the spica cast is in place, AP
and lateral x-rays are obtained to ensure that length and angular and rotational alignment are maintained. We observe all
patients for 24 hours after spica application to be sure that the
child is not at risk for neurovascular compromise or compartment syndrome. Gore-Tex liners can be used to decrease the
skin problems of diaper rash and superficial infection. Several
centers have found that this has been beneficial, justifying the
cost of a Gore-Tex liner.
For the single leg spica or “walking spica” technique, the
long leg cast is applied with approximately 45 degrees of knee
flexion, and when the remaining cast is placed, the hip is flexed
45 degrees and externally rotated 15 degrees. The hip should
be reinforced anteriorly with multiple layers of extra fiberglass. The pelvic band should be fairly wide so that the hip
is controlled as well as possible. A substantial valgus mold is
important to prevent varus malangulation. We leave the foot
out, stopping the distal end of the cast in the supramalleolar
area, which is protected with plenty of extra padding. Seven to
10 days after injury, the child returns to clinic anticipating the
need for cast wedging, if radiographs show the very common
mild increase in shortening and varus angulation. Most toddlers pull to a stand and begin walking in their walking cast
about 2 to 3 weeks after injury.
If excessive angulation occurs, the cast should be changed,
with manipulation in the operating room. Casts can be wedged
for less than 15 degrees of angulation. If shortening of more
than 2 cm is documented, the child should be treated with
cast change, traction, or conversion to external fixation, using
lengthening techniques if the shortening is not detected until
the fracture callus has developed. When conversion to external fixation is required, we recommend osteoclasis (either
closed or open if needed) at the time of the application of the
external fixator, with slow lengthening over a period of several
weeks (1 mm per day) to reestablish acceptable length
(Fig. 27-8).
Generally, the spica cast is worn for 4 to 8 weeks, depending
on the age of the child and the severity of the soft tissue damage
accompanying the fracture. Typically, an infant’s femoral shaft
fracture will heal in 3 to 4 weeks; and a toddler’s fracture will
heal in 6 weeks. After the cast is been removed, parents are
encouraged to allow their children to stand and walk whenever
the child is comfortable; most children will need to be carried
or pushed in a stroller for a few days until hip and knee stiffness gradually results. Most joint stiffness resolves spontaneously in children after a few weeks. It is unusual to need formal
physical therapy. In fact, aggressive joint range-of-motion exercises with the therapist immediately after cast removal make
children anxious, and may prolong rather than hasten recovery.
A few follow-up visits are recommended in the first year after
femur fracture, analyzing gait, joint range of motion, and leg
lengths.
05/06/14 2:13 PM
Traction and Casting
After preparation of the thigh circumferentially from the knee
to the midthigh, the limb is draped in a sterile manner. The
knee is held in the position in which it will remain during trac-
tion; that is, if 90/90 traction is being used, the traction pin
should be inserted with the knee bent 90 degrees. Because this
technique is typically used in very young children, traction pin
is placed in the operating room under general anesthesia. The
technique is safest and most efficient if it is done with fluoroscopic x-ray control for optimal pin location. The location of
pin insertion is 1 fingerbreadth above the patella with the knee
extended or just above the flare of the distal femur. A small
puncture wound is made over the medial side of the femur. A
medial-to-lateral approach is used so that the traction pin does
not migrate into the area of the femoral artery that runs through
Hunter canal on the medial side of the femur. The best traction
pin is the largest available threaded Steinmann pin. The pin is
placed parallel to the joint surface5 to help maintain alignment
while in traction. After the pin protrudes through the lateral
cortex of the femur, a small incision is made over the tip of
the pin. The pin is then driven far enough through the skin to
allow fixation with a traction bow. If 90/90 traction is used, a
short leg cast can be placed with a ring through its midportion
to support the leg. Alternatively, a sling to support the calf may
be used. If a sling is used, heel cord stretching should be performed while the patient is in traction.
After the skeletal traction pin has been placed in the distal
femur, traction is applied in a 90/90 position (the hip and knee
flexed 90 degrees) (Fig. 27-12) or in an oblique position (the
hip flexed 20 to 60 degrees). If the oblique position is chosen,
a Thomas splint or sling is necessary to support the leg. The
fracture may be allowed to begin healing in traction, and x-rays
should be obtained once or twice a week to monitor alignment
and length. In preschool age children, traction will be necessary for 2 to 3 weeks; in school-age children, a full 3 weeks of
traction is usually necessary before the fracture is stable enough
to permit casting. In a child under 10 years of age, the ideal
fracture position in traction should be less than 1 cm of shortening and slight valgus alignment to counteract the tendency to
angulate into varus in the cast and the eventual overgrowth that
Figure 27-11 This tomogram shows a bony bridge caused by a
tibial traction pin that was placed for femoral fracture.
Figure 27-12 In 90-degree/90-degree traction, a femoral pin is used
and the lower leg and foot are supported with a short leg cast or a sling.
Since as early as the 18th century, traction has been used for
management of femur fractures. Vertical overhead traction with
the hip flexed 90 degrees and the knee straight was introduced
by Bryant in 1873,25,38 but this often resulted in vascular insufficiency,154 and it is now rarely used for treatment of femoral
fractures. Modified Bryant traction, in which the knee is flexed
45 degrees, increases the safety of overhead skin traction.55
Traction prior to spica casting is indicated when the fracture is length unstable and the family and surgeon agree that
nonoperative measures are preferred. In general, skeletal traction then Spica casting is not currently used for children who
are older than 12 years of age, because of the significant risk
of shortening and angular malunion; in children older than
12 years of age, internal fixation is recommended. Children
who rapidly shortened in an early spica cast can be salvaged
with cast removal and subsequent traction. The limit of skin
traction is the interface between skin and tape or skin and
foam traction boot. Skin complications, such as slough and
blistering, usually occur when more than 5 lb of traction is
applied. When more than 5 lb of traction is required, or simply for ease in patient management, skeletal traction can be
used to maintain alignment.5
The distal femur is the location of choice for a traction
pin.5,48,177 Although proximal tibial traction pins have been recommended by some clinicians,92 growth arrest in the proximal
tibial physis and subsequent recurvatum deformity have been
associated with their use (Fig. 27-11). Also, knee ligament and
meniscal injuries that sometimes accompany femoral fractures
may be aggravated by the chronic pull of traction across the knee.
Traction Pin Insertion: Technique
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may occur (average 0.9 cm). If this method is used for adolescents (11 years or older), normal length should be maintained.
then using that cast to apply traction while immobilizing the
child in the 90/90 position. The authors recommend avoiding
traction on a short leg cast, leaving the foot out, and using less
hip and knee flexion (Fig. 27-14).
Spica Casting, with Traction Pin Incorporated
In rare circumstances, a child’s femur fractures best treated by
spica casting, incorporating a traction pin in the cast to maintain
fracture length. This technique may be particularly useful in an
environment where there are limited resources. In a study by
Gross et al.,68 72 children with femoral fractures were treated
with early cast brace/traction management. In this technique, a
traction pin is placed in the distal femur and then incorporated
in a cast brace. The traction pin is left long enough to be used
for maintaining traction while the patient is in the cast brace or
traction is applied directly to the cast. The patient is allowed
to ambulate in the cast brace starting 3 days after application.
Radiographs are taken of the fracture in the cast brace to document that excessive shortening is not occurring. The patient then
is returned to traction in the cast brace until satisfactory callus is
present to prevent shortening or angular deformity with weight
bearing. The technique was not effective in older adolescents
with midshaft fractures but achieved excellent results in children
5 to 12 years of age. The average hospital stay was 17 days.
Flexible Intramedullary Nail Fixation for
In most centers, flexible intramedullary nailing is the standard
treatment for midshaft femur fractures in children between the
ages of 5 and 11 years old. The flexible intramedullary nailing
technique can be performed with either stainless steel nails168,209
or titanium elastic nails.
The popularity of flexible intramedullary nailing results
from its safety, efficacy, and ease of implant removal. The flexible nailing technique offers satisfactory fixation, enough stress
at the fracture site to allow abundant callous formation, and
relatively easy insertion and removal. The implants are inexpensive and the technique has a short learning curve. The primary limitation of flexible nailing is the lack of rigid fixation.
Length-unstable fractures can shorten and angulate, especially
in older and heavier children. Compared to children with rigid
fixation, children who have their femur fracture treated with
flexible nailing clearly have more pain and muscle spasm in the
early postoperative period. The surgeon should take this into
consideration in planning the early rehabilitation.
As the flexible nailing technique has become more popular, there have been many studies to refine the technique and
indications, and to elucidate the inherent limitations of fixation
with flexible implants. Mechanical testing of femoral fracture
fixation systems showed that the greatest rigidity is provided by
an external fixation device and the least by flexible intramedullary rodding.115 Stainless steel rods are stiffer than titanium in
bending tests. A study comparing steel to titanium flexible nails
found a higher complication rate in the titanium group.209 They
reported that a typical 3.5-mm stainless steel nail has the same
Complications of Spica Casting
Comparative studies and retrospective reviews have demonstrated unsatisfactory results in a small, yet significant, percentage of patients treated with skeletal traction.84,92,108,169 Recently,
increased attention has been focused on the risk of compartment syndrome in children treated in 90/90 spica cast.151
Mubarak et al.151 presented a multicenter series of nine children
with an average age of 3.5 years who developed compartment
syndrome of the leg after treatment of a low-energy femur fracture in a 90/90 spica cast. These children had extensive muscle
damage and the skin loss around the ankle (Fig. 27-13). The
authors emphasize the risk in placing an initial below knee cast,
Cast
completed
A
B
C
Figure 27-13 This drawing shows the pathogenesis of leg compartment syndrome caused by
improper application of a spica cast. A: In the original description, a short leg cast was applied first, and
used to pull the fracture out to length, as shown in this drawing. B: As the cast was completed, traction held on the short leg cast portion put pressure in the popliteal fossa. C: After the child awakens
from general anesthesia, there is shortening of the femur from muscular contraction which causes
the thigh and leg to slip somewhat back into the spica. This causes pressure to occur at the corners
of the cast. (Reprinted from Mubarak SJ, Frick S, Sink E, et al. Volkmann contracture and compartment syndromes after femur fractures in children treated with 90/90 spica casts. J Pediatr Orthop.
2006;26(5):570.)
LWBK1326-C27-p987-1026.indd 998
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A
B
C
D
Figure 27-14 Authors recommended technique of spica cast application. A: The patient is placed
on a child’s fracture table. The leg is held in about 45-degree angle of flexion at the hip and knee with
traction applied to the proximal calf. B: The 1½ spica is then applied down to the proximal calf. Molding of the thigh is accomplished during this phase. C: The x-rays of the femur are obtained and any
wedging of the cast that is necessary can occur at this point in time. D: The leg portion of the cast and
the cross bar are applied. The belly portion of the spica is trimmed to the umbilicus. (Reprinted from
Mubarak SJ, Frick S, Sink E, et al. Volkmann contracture and compartment syndromes after femur
fractures in children treated with 90/90 spica casts. J Pediatr Orthop. 2006;26(5):571.)
strength as a 4 mm diameter titanium nail. Lee et al.115 analyzed a group of synthetic fractured femurs instrumented with
Enders rods and determined that there was sufficient axial
and torsional stiffness to allow “touch-down weight bearing”
despite fracture type. Gwyn et al.71 similarly showed that 4-mm
titanium rods impart satisfactory torsional stability regardless
of fracture pattern. Recognizing this flexibility, the French pioneers114,120 of elastic nailing stressed the critical importance of
proper implant technique, including prebending the nails so
that the apex of the bend was at the fracture site, and so that
the two implants balance one another to prevent bending and
control rotation. Frick et al.61 found there to be greater stiffness
and resistance to torsional deformation when retrograde nails
are contoured into a double C pattern than with the antegrade
C and S configuration. Sagan et al.178 noted that apex anterior
malunion is less likely if at least one nail has its shoe tip point
anteriorly, such that the nail is in procurvatum.
The prevailing technique for flexible nail insertion at most
centers throughout the world has been retrograde, with small
medial and lateral incisions just above the distal femoral physis.
However, some prefer an antegrade technique, with entry in
the subtrochanteric area. The primary advantages of a proxi-
LWBK1326-C27-p987-1026.indd 999
mal insertion site are a fewer knee symptoms postoperatively.
Bourdelat21 compared retrograde and antegrade (ascending and
descending) flexible intramedullary rodding in a group of 73
femoral fractures. An antegrade transtrochanteric approach was
recommended by Carey and Galpin,31 who reported excellent
results in 25 patients without growth arrest of the upper femur
and no osteonecrosis. Satisfactory alignment and fracture healing were obtained in all patients.
Retrograde intramedullary nailing with Ender nails or
titanium nails has been reported by Ligier et al.,120 Mann et
al.,127 Heinrich et al.,79 Herscovici et al.,85 and others.31,104,135
Heinrich et al.79 recommended a 3.5-mm Ender nail in children 6 to 10 years of age and a 4-mm nail in children over
10 years of age. Ligier et al.120 used titanium nails ranging from
3 to 4 mm inserted primarily in a retrograde fashion. Heinrich
et al.80 recommended flexible intramedullary nails for fixation of diaphyseal femoral fractures in children with multiple
system injury, head injury, spasticity, or multiple long bone
fractures. Flynn et al.58 published the first North American
experience with titanium elastic nails. In this multicenter study,
57/58 patients had an excellent or satisfactory result, there was
no loss of rotational alignment, but four patients healed with
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an angular malunion of more than 10 degrees. Narayanan
et al.152 looked at one center’s learning curve with titanium elastic nails, studying the complications of 79 patients over a 5-year
period. Nails that were bent excessively away from the bone led
to irritation at the insertion site in 41. The center also had eight
malunions and two refractures. They noted that complications
could be diminished by using rods with similar diameter and
contour, and by avoiding bending the distal end of the nail way
from the bone and out into the soft tissues. Luhmann et al.123
reported 21 complications in 43 patients with titanium elastic
nails. Most of the problems were minor, but a hypertrophic
nonunion and a septic joint occurred in their cohort. They suggested that problems could be minimized by using the largest
nail possible and leaving only 2.5 cm out of the femoral cortex.
Flexible nails are removed after fracture union at most centers. However, some surgeons choose to leave the implants permanently. There is a theoretical concern that if flexible nails are
left in young children, they will come to lie in the distal diaphysis as the child grows older. This may create a stress riser in the
distal diaphysis, leading to a theoretical risk of fracture (Fig.
27-15). Morshed et al.150 performed a retrospective analysis of
24 children treated with titanium elastic nails and followed for
an average of 3.6 years. The original plan with these children
was to retain their implants. However, about 25% of the children had their nails removed for persistent discomfort.
Fixation with Flexible Intramedullary
Nails: Technique
Preoperative Planning. The ideal patient for flexible intramedullary nailing is the child between the ages of 5 and 11 years
A
LWBK1326-C27-p987-1026.indd 1000
A
B
Figure 27-15 A: A few years after titanium lasting nailing, the nails
have migrated proximally with growth, creating a stress riser and
the subsequent insufficiency fracture. B. The refracture was treated
with removal of the old nails and replacement with longer implants.
old with a length-stable femur fracture, in the mid-80% of
the diaphysis (Fig. 27-16), who has a body weight less than
50 kg.148 Unstable fracture patterns can also be treated with
B
Figure 27-16 Titanium elastic nailing
of the midshaft femur fracture through
a benign lytic defect. A: Portable
radiograph of a short oblique femur
fracture through a benign lytic defect.
B: AP radiograph taken several weeks
after surgery that show the fracture
well aligned with titanium elastic nail
internal fixation and early callus at the
fracture site.
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A, B
C
Figure 27-17 A: This high-energy, midshaft femur fracture was treated with titanium nails.
B: A large butterfly fragment was dislodged during nail insertion. Because the fracture is now lengthunstable, the surgeon wisely chose to protect the child for a few weeks in a one-leg spica cast.
C: The fracture healed and excellent alignment. Note how the nails have wound around each other.
This can make nail removal more difficult.
flexible nailing, but the risk of shortening and angular malunion is greater,187 and supplemental immobilization during
early healing phase may be valuable.
Initial radiographs should be studied carefully for fracture
lines that propagate proximally and distally, and might be
otherwise unnoticed (Fig. 27-17). Although it is technically
difficult to obtain satisfactory fixation with a retrograde technique when the fracture is near the distal metaphysis, a recent
biomechanical study138 demonstrated that retrograde insertion
provides better stability than antegrade insertion for distal femoral shaft fractures. Nail size is determined by measuring the
minimum diameter of the diaphysis, then multiplying by 0.4
to get nail diameter. For instance, if the minimum diameter of
the diaphyseal canal is 1 cm, the 4-mm nails are used. Always
choose the largest possible nail size that permits two nails to fit
medullary canal.
Flexible nailing is most effectively performed on a fracture
table, with a fracture reduced to near-anatomic position before
incisions are made. Alternatively, a fluoroscopic table can
be used, but the surgeon should assure that a reduction can
be obtained prior to the start of the procedure, and extra assistance may be necessary.
The procedure described is with titanium elastic rods, but
other devices are available and can be used with slight variations in procedure.
Rod Bending. The distance from the top of the inserted rod to
the level of the fracture site is measured, and a gentle 30-degree
LWBK1326-C27-p987-1026.indd 1001
bend is placed in the nail. The technique of elastic fixation of
femoral fractures as described by Ligier et al.120 requires that
a bend be placed in the midportion of the rod at the level of
the fracture site. This produces a spring effect (Fig. 27-18) that
adds to the rigidity of the fracture fixation. The spread of the
rods in opposite directions provides a “prestressed” fixation,
which increases resistance to bending. The opposite bends of
the two rods at the level of the fracture significantly increase
resistance to varus and valgus stress, as well as torsion. A second bend is sometimes helpful near the entering tip of the
nail to facilitate clearance of the opposite cortex during initial
insertion. Based on the report by Sagan et al.,178 sagittal plane
configuration should be considered as well. An apex-posterior
bend in one of the nails, with the nail shoe pointing anteriorly
in the proximal femur, resists apex-anterior malunion.
Most pediatric femur fractures are fixed with 4-mm diameter nails; in smaller children, 3.5-mm nails may be necessary.
Two nails of similar size should be used, and they should be as
large as possible. Using nails that are too small, or mismatched
in size, increases the rate of complications.152 It is very unusual
to use nails smaller than 3.5 mm, except in the very youngest,
smallest children.
Retrograde Insertion. After the child is placed on the fracture
table and the fracture reduced as much as possible, the leg is
prepared and draped with the thigh (hip to knee) exposed. The
image intensifier is used to localize the placement of skin incisions by viewing the distal femur in the AP and lateral planes.
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Weight
a
a
B
a-a
A
C
Incisions are made on the medial and lateral side distal to the
insertion site in the bone. The proximal end of the 2- to 3-cm
incision should be at or just distal to the level of the insertion
site, which is about 2.5 to 3 cm proximal to the distal femoral
physis (Fig. 27-19). A 4.5-mm drill bit or awl is used to make
a hole in the cortex of the bone. The distal femoral metaphysis
A
LWBK1326-C27-p987-1026.indd 1002
B
C
Figure 27-18 A: Stability from flexible rods comes from proper technique.
B: Torsional stability results from divergence of the rods in the metaphysis.
C: Resistance to sagittal and coronal
bending results from spreading of the
prebent rods through the diaphysis, as
well as the size and material properties
of the rods. Elastic rods return to their
predetermined alignment when loaded
unless plastic deformation occurs.
is opened 2.5 cm proximal to the distal femoral physis using
a drill or awl. The drill is then steeply angled in the frontal
plane to facilitate passage of the nail through the dense pediatric metaphyseal bone.
Upon insertion the rod glances off the cortex as it advances
toward the fracture site. Both medial and lateral rods are
D
Figure 27-19 A: A drill bit slightly
larger than the nail that will be
implanted is used to broach the
cortex. The drillbit can initially
be placed in a perpendicular orientation. B: once the cortex is
broached, the drill bit is dropped
to a sharply oblique angle and the
medullary canal is entered. C: The
contoured nails inserted following
the track of the drillbit. The angle
insertion is sharply oblique so that
the nail tip bounces off the opposite cortex and precedes up the
canal. D: After the first nail is just
across the fracture site, the second
nail is inserted in a similar fashion.
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inserted to the level of the fracture. At this point, the fracture
reduction is optimized if necessary with a radiolucent fracture
reduction tool which holds the unstable femoral fracture in the
appropriate position to allow fixation. The surgeon judge which
nail will be most difficult to get across the fracture site, and pass
it first. If the easier nail is passed first, it may stabilize the two
fragments such that the second, more difficult nail, cannot be
passed easily. The two nails then are driven into the proximal
end of the femur, with one driven toward the femoral neck
and the other toward the greater trochanter. On the lateral,
one nail should have its tip pointing anteriorly. When passing
the second nail across the fracture site and rotating it, care must
be taken not to wind one rod around the other. After the nails
are driven across the fracture and before they are seated, fluoroscopy is used to confirm satisfactory reduction of the fracture
and to ensure that the nails did not comminute the fracture as
they were driven into the proximal fragment.
The nails are pulled back approximately 2 cm, the end of
each nail is cut, then driven back securely into the femur. The
end of the nail should lie adjacent to the bone of the distal
femoral metaphysis, exposed just enough to allow easy removal
once the fracture is healed. Do not bend the exposed to distal
tip of the nail away from femoral metaphysis as this will irritate
surrounding tissues.
A proximal insertion site can also be used. An insertion site
through the lateral border of the trochanter avoids creating the
stress riser that results from subtrochanteric entry.
Technique Tip. Mazda et al.132 emphasized that for insertion
of titanium elastic nails, the nails have to be bent into an even
curve over the entire length, and the summit of the curve must
be at the level of the fracture or very close to it in comminuted
fractures. The depth of curvature should be about three times
the diameter of the femoral canal. Flynn et al.58 also stressed the
importance of contouring both nails with similar gentle curvatures, choosing nails that are 40% of the narrowest diaphyseal
diameter and using medial and lateral starting points that are at
the same level in the metaphysis.
In length-unstable fractures, an endcap has been shown to
confer increased stability that might lessen the risk of shortening208 and nail backout.
Postoperative Management. A knee immobilizer is beneficial
in the early postoperative course to decrease knee pain and
quadriceps spasm. When the flexible nailing technique is used
for length-unstable fracture, walking (or one leg) spica is recommended, generally for about 4 to 6 weeks until callus is
visible on radiographs. For length-stable fractures, touch-down
weight bearing could begin as soon as the patient is comfortable. Gentle knee exercises and quadriceps strengthening can
be begun, but there should be no aggressive passive motion of
the knee, which increases the motion at the fracture site and
increases quadriceps spasm. Postoperative knee motion does
return to normal over time. Full weight bearing generally is
tolerated by 6 weeks. Ozdemir et al.160 recommended the use of
postoperative functional bracing, demonstrating effectiveness
in a group of patients treated with elastic rodding. Such postoperative support may occasionally be required, but in most
cases it appears not to be needed.
LWBK1326-C27-p987-1026.indd 1003
The nails can be removed 6 to 12 months after injury when
the fracture is fully healed, usually as an outpatient procedure.
Complications of Flexible Intramedullary Nailing
Complications are relatively infrequent after flexible intramedullary nailing. In 351 fractures reported in seven studies10,31,53,80,120,123,132 one nonunion, one infection, and no
occurrence of osteonecrosis were reported. Approximately 12%
of patients had malunions, most often mild varus deformities,
and approximately 3% had clinically significant leg length
discrepancies from either overgrowth or shortening. A recent
study noted overgrowth of more than 1 cm in 8.2% of preschool children treated with titanium elastic nailing.149 This is
a much higher rate of overgrowth than seen in older children,
suggesting the technique should be used infrequently in preschool children. Mazda et al.132 pointed out a technique-related
complication that occurred in 10 of their 34 patients: Rods
were left too long and caused painful bursae and limited knee
flexion. All 10 patients had the nails removed 2 to 5 months
after surgery. Flexible nails inserted in a retrograde fashion may
also penetrate into the knee joint, causing an acute synovitis174
In a multicenter study58 that included 58 femoral fractures stabilized with titanium elastic nails, irritation of the soft tissue
near the knee by the nail tip occurred in four patients (7%),
leading to a deeper infection in two patients. This study also
reported one refracture after premature nail removal, leading to
a recommendation that nail removal be delayed until callus is
solid around all cortices and the fracture line is no longer visible. Ozdemir et al.160 measured overgrowth with a scanogram
and found that the average increase in length was 1.8 mm, suggesting that significant femoral overgrowth is not seen with this
method of treatment.
Flynn et al.59 compared traction and spica cast with titanium
elastic nails for treatment of femoral fractures in 83 consecutive school-aged children. The three unsatisfactory results were
treated with traction followed by casting. The overall complication rate was 34% in the traction group and 21% in the elastic
nail group.
An international multicenter study focused on factors that
predict a higher rate of complications after flexible nailing of
pediatric femoral shaft fractures.20 Analyzing 234 fractures
in 229 patients from six different Level 1 trauma centers,
the authors found significantly more problems in older,
heavier children. A poor outcome was five times more likely
in patients who weigh more than 108.5 lb. A poor outcome
was also almost four times more likely in patients older than
11 years old. The authors concluded that results were generally excellent for titanium elastic nailing, but poor results were
more likely in children older than 11 years and heavier than
50 kg. Ho et al.87 reported a 34% complication rate in patients
10 years and older, but only a 9% complication rate in patients
younger than 10 years, emphasizing the concept that complications of flexible nailing are higher in older, heavier children.
Salem and Keppler179 noted a 47% incidence of torsional
malunion ≥15 degrees in the patients they treated at one center
in Germany. These authors could not determine if the torsional
malunion was due to instability after fixation, or faulty surgical
05/06/14 2:14 PM
technique. In either case, the findings call attention to the need
for rotational assessment after fixation.
External Fixation for Femoral
Shaft Fractures
External fixation of femoral shaft fractures offers an efficient,
convenient method to align and stabilize the fractured pediatric femur. It is the method of choice when severe soft tissue
injury precludes nailing or submuscular plating, when a fracture shortens excessively in a spica cast, or as part of a “damagecontrol” strategy.147 In head-injured or multiply injured patients
and those with open fractures, external fixation offers an excellent method of rapid fracture stabilization. It is also valuable
for very proximal or distal fractures, where options for flexible nailing, plating, or casting are limited. External fixation is
particularly valuable for the benign pathologic fracture (e.g.,
through a nonossifying fibroma) at the distal metaphyseal–
diaphyseal junction (Fig. 27-20), where the fracture will heal
rapidly, but angular malunion must be avoided.
Aronson and Tursky6 reported their early experience with
44 femoral fractures treated with primary external fixation
and early weight bearing. Most patients returned to school by
4 weeks after fracture and had full knee motion by 6 weeks after
the fixator was removed. In this early study, end-on alignment
was the goal and overgrowth was minimal. Recently, Matzkin
et al.131 reported on a series of 40 pediatric femur fractures
treated with external fixation. Seventy-two percent of their
series were dynamized prior to external fixator removal, and
their refracture rate was only 2.5%. They had no overgrowth,
but one patient ended up 5 cm short.
Following early enthusiasm for the use of external devices,
the last decade saw waning interest in their use because of complications with pin track infections, pin site scarring, delayed
union, and refracture. These complications, coupled with
the very low complication rate from flexible nailing, led to a
decline of external fixation for pediatric femoral shaft fractures.
Data from comparison studies also contributed to the change.
Bar-On et al.10 compared external fixation with flexible intramedullary rodding in a prospective randomized study. They found
that the early postoperative course was similar but that the time
to return to school and to resume full activity was less with
intramedullary fixation. Muscle strength was better in the flexible intramedullary fixation group at 14 months after fracture.
Parental satisfaction was also significantly better in the flexible
intramedullary rodding group. Bar-On et al.10 recommended
that external fixation be reserved for open or severely comminuted fractures.
Frame Application: Technique
During preoperative planning, the fracture should be studied
carefully for comminution, or fracture lines that propagate
proximally or distally. The surgeon should assure that the fixator devices available are long enough to span the distance
between the optimal proximal and distal pin insertion sites.
A
B
Figure 27-20 AP (A) and lateral (B) radiographs a low-energy short oblique fracture through a fibrous
cortical defect in the distal femur; this type of fracture is not unusual. The surgeon judged that there
was enough distance between the fracture site and the growth plate to allow external fixation.
LWBK1326-C27-p987-1026.indd 1004
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C
D
Figure 27-20 (continued) AP (C) and lateral (D) X3 weeks after
external fixation show early callus, slight varus on the AP, and good
alignment on the lateral. The external fixation was removed shortly
after this x-ray and the child was placed in a long leg cast, with
weight bearing is tolerated.
Figure 27-21 A: This proximal spiral femur
fracture was deemed length unstable and a
poor candidate for titanium elastic nails. The
surgeon chose an external fixator, rather
than a plate. B: Eight weeks after injury, the
fracture is healing in excellent alignment and
there is good early callous. Fixator removal is
easier than plate removal.
LWBK1326-C27-p987-1026.indd 1005
A
As in the elastic nailing technique, either the fracture table
or radiolucent table can be used, although the fracture table is
much more efficient, as an anatomic reduction can be obtained
before prepping and draping. First we try to reduce the fracture
both in length and alignment. If the fracture is open, it should
be irrigated and debrided before application of the external
fixation device. With the fracture optimally aligned, fixation is
begun. The minimal and maximal length constraints characteristic of all external fixation systems must be kept in mind, and
the angular adjustment intrinsic to the fixation device should
be determined. Rotation is constrained with all external fixation systems once the first pins are placed. That is, if parallel
pins are placed with the fracture in 40 degrees of malrotation,
a 40-degree malalignment will exist. Rotational correction must
be obtained before placing the pins in the proximal and distal
shafts of the femur (Fig. 27-21).
Application of the fixator is similar no matter what device is
chosen. One pin is placed proximally in the shaft, and another
pin is placed distally perpendicular to the long axis of the shaft.
Alignment is based on the long axis of the shaft, rather than to
the joint surface. Rotation should be checked before the second
pin is placed because it constrains rotation but not angulation
or length. After pins are correctly placed, all fixation nuts are
secured and sterile dressings are applied to pins.
Technique Tips. Pin sizes vary with manufacturers, as do
drill sizes. In general the pins are placed through predrilled
holes to avoid thermal necrosis of bone. Sharp drills should be
used. The manufacturer’s recommendation for drill and screw
sizes should be checked before starting the procedure. Some
B
05/06/14 2:14 PM
self-drilling and self-tapping pins are available. At least two
pins should be placed proximally and two distally. An intermediate or auxiliary pin may be beneficial.
Postoperative Care. The key to preventing pin site irritation is avoiding tension at the skin–pin interface. We recommend that our patients clean their pin sites daily with soap and
water, perhaps as part of regular bath or shower. Showering is
allowed once the wound is stable and there is no communication between the pin and the fracture hematoma. Antibiotics
are commonly used at some point while the fixator is in place,
because pin site infections are common and easily resolved
with antibiotic treatment, usually cephalosporin.
There are two general strategies regarding fixator removal.
The external fixation device can be used as “portable traction.” With this strategy, the fixator is left in place until
early callus stabilizes the fracture. At this point, usually 6
to 8 weeks after injury, the fixator device is removed and a
walking spica cast is placed. This minimizes stress shielding from the fixator, and allows time for the pin holes to
fill in while the cast is on. The alternative, classic strategy,
involves using the fixator until the fracture is completely
healed. Fixator dynamization, which is difficult in small,
young children, is essential for this classic strategy. The surgeon should not remove the device until three or four cortices show bridging bone continuous on AP and lateral x-rays,
typically 3 to 4 months after injury.
Complications of External Fixation
The most common complication of external fixation is pin track
irritation/infection, which has been reported to occur in up to
72% of patients.145 This problem generally is easily treated with
oral antibiotics and local pin site care. Sola et al.191 reported a
decreased number of pin track infections after changing their
pin care protocol from cleansing with peroxide to simply having the patient shower daily. Superficial infections should be
treated aggressively with pin track releases and antibiotics.
Deep infections are rare, but if present, surgical debridement
and antibiotic therapy are usually effective. Any skin tenting
over the pins should be released at the time of application or
at follow-up.
In a study of complications of external fixators for femoral
fractures, Gregory et al.65 reported a 30% major complication
rate and a high minor complication rate. Among the major
complications were five refractures or fractures through pin
sites. Another comprehensive study of external fixation complications32 found an overall rate of refracture of 4.7%, with
a pin track infection rate of 33.1%. Skaggs et al.189 reviewed
the use of external fixation devices for femoral fractures and
found a 12% rate of secondary fractures in 66 patients. Fractures with fewer than three cortices with bridging callus at the
time of fixator removal had a 33% risk of refracture, whereas
those with three or four cortices showing bridging callus had
only a 4% rate of refracture. Other reports in the literature with
smaller numbers, but still substantial experience, document
refracture rates as high as 21.6% with more significant complications.45,49,66,91,145,166,185 Despite the complications, patients
and treating physicians have found wound care and ability to
LWBK1326-C27-p987-1026.indd 1006
lengthen through the fracture to be of great benefit of external
fixation.
Although joint stiffness has been noted in older patients
treated with external fixation, it is relatively uncommon in
children with femoral fractures unless major soft tissue injury
is present.52
Rigid Intramedullary Rod Fixation for
With reports by Beaty et al.12 and others in the early 1990s
alerting surgeons that antegrade intramedullary nailing can
be complicated by osteonecrosis of the proximal femur,
flexible nailing (either antegrade or retrograde) quickly
became more popular than standard locked, antegrade rigid
intramedullary nailing. Recently, however, locked antegrade
femoral nailing for pediatric femur fractures has enjoyed a
resurgence of interest with the introduction of newer generation implants that allow a very lateral trochanteric entry
point. These newer implant systems avoid a piriformis entry
site, reducing (but perhaps not completely eliminating) the
risk of osteonecrosis.88,107 Antegrade-locked intramedullary fixation is particularly valuable for adolescent femur
fractures. Comparative studies by Reeves et al.169 and Kirby
et al.,108 as well as retrospective reviews of traction and casting,
suggest that femoral fractures in adolescents are better treated
with intramedullary fixation12,29,45,63,64,68,84,103,108,120,199,212,213
than with traditional traction and casting (Table 27-3).
Keeler et al.107 reported on 80 femur fractures in patients
8 to 18 years old treated with a lateral trochanteric entry
starting point. There was no osteonecrosis, no malunion,
and a 2.5% infection rate.
Length-unstable adolescent femur fractures benefit from
interlocking proximally and distally to maintain length and
rotational alignment.13,24,73 Beaty et al.12 reported the use of
interlocking intramedullary nails for the treatment of 31 femoral shaft fractures in 30 patients 10 to 15 years of age. All
fractures united, and the average leg length discrepancy was
0.51 cm. No angular or rotational malunions occurred. All
nails were removed at an average of 14 months after injury; no
refracture or femoral neck fracture occurred after nail removal.
One case of osteonecrosis of the femoral head occurred, which
was thought to be secondary to injury to the ascending cervical
artery during nail insertion.
Reamed antegrade nailing in children with an open proximal femoral physis must absolutely avoid the piriformis fossa,
because of the risk of proximal femoral growth abnormalities,167
the risk of osteonecrosis of the femoral head,12,141,165,196 the size of
the proximal femur, and the relative success of other treatment
methods. However, Maruenda-Paulino et al.129 reported good
results using 9-mm Kuntscher rods in children 7 to 12 years of
age, and Beaty et al.12 reported the use of pediatric “intermediate”
interlocking nails for femoral canals with diameters as small as 8
mm. Townsend and Hoffinger202 and Momberger et al.146 published reviews of trochanteric nailing in adolescents with very
good results. The combined series includes 82 patients of age 10
to 17+ 6 years with no reported cases of osteonecrosis and no
significant alteration in proximal femoral anatomy.
05/06/14 2:14 PM
Table 27-3
Results of Treatment of Femoral Shaft Fractures in Adolescents
Series
No. of Patients
108
Average Age
(Range) in Years
Treatment
Results and Complications (n)
13
12 + 7
(10 + 11–15 + 6)
Traction + cast
Short >2.5 cm (2)
Significant residual angulation (4)
12
12 + 0
(10 + 10–15 + 7)
Intramedullary nailing
No overgrowth
No significant residual angulation
Ziv et al.213
17
8+3
(6–12)
(9 Rush pins, 9 Kuntscher
nails)
No leg length discrepancy >1 cm
Change in AID 0.5–1 cm = 3 with
Kuntscher nails
Reeves et al.169
41
12 + 4
(9 + 9–16 + 4)
Traction + cast
Delayed union (4)
Malunion (5)
Growth disturbance (4)
Psychotic episodes (2)
49
14 + 11
(11–16 + 10)
No infection, nonunion, or malunion
Beaty et al.12
30
12 + 3
(10–15)
Overgrowth >2.5 cm (2)
AVN femoral head (1)
Aronson et al.6
42
9+7
(2 + 5–17 + 8)
External fixation
8.5% pin infection
10% cast or reapplication
Ligier et al.120
123
10
(5–16)
Flexible IM rods
1 infection
13 wound ulcerations
2 LLD >2 cm
Mazda et al.132
34
9.5
(6–17)
Flexible IM rods
1–1.5 cm overgrowth (3)
1–15-degree malalignment (2)
Kirby et al.
LLD, leg length discrepancy.
Open fractures in older adolescents can be effectively
treated with intramedullary rodding, either as delayed or primary treatment, including those caused by gunshot wounds
and high-velocity injuries.16,200 Antegrade intramedullary rod
insertion maintains length, prevents angular malunion and
nonunion, and allows the patient to be rapidly mobilized and
discharged from the hospital. However, other techniques with
fewer potential risks should be considered.
Retrograde rodding of the femur has become an accepted
procedure in adults.159,171 In a large patient approaching skeletal maturity (bone age >16 years) but with an open proximal
femoral physis and an unstable fracture pattern, one might consider this treatment as a way to avoid the risk of osteonecrosis yet stabilize the fracture. If growth from the distal femur is
predicted to be less than 1 cm, leg length inequality should not
be a problem. Ricci et al.171 have shown that the complication
rate with this technique compares favorably to that of antegrade
nailing, with a higher rate of knee pain but a lower rate of hip
pain. The malunion rate was slightly lower with retrograde rodding than with antegrade rodding of the femur.
Antegrade Transtrochanteric Intramedullary
Nailing: Technique
The patient is placed either supine or in the lateral decubitus
position on a fracture table. The upper end of the femur is
approached through a 3-cm longitudinal incision proximal that
allows access to the lateral trochanteric entry point. The skin
incision can be precisely placed after localization on both the
LWBK1326-C27-p987-1026.indd 1007
AP and lateral views. Dissection should be limited to the lateral
aspect of the greater trochanter, avoiding the piriformis fossa.
This prevents dissection near the origin of the lateral ascending
cervical artery medial to the piriformis fossa. The rod should be
inserted through the lateral aspect of the greater trochanter. In
children and adolescents, it’s preferable to choose the smallest
implant, with the smallest diameter reaming, to avoid damage
to the proximal femoral insertion area.
The technique for reaming and nail insertion varies according to the specifics of the implant chosen. In general, the smallest rod that maintains contact with the femoral cortices is used
(generally 9 mm or less) and is locked proximally and distally
(Fig. 27-22). Only one distal locking screw is necessary, but
two can be used.106 Rods that have an expanded proximal cross
section should be avoided, as they require excessive removal
of bone from the child’s proximal femur. The proximal end of
the nail should be left slightly long (up to 1 cm) to make later
removal easier. The rod chosen should be angled proximally and
specifically designed for transtrochanteric insertion (Fig. 27-23).
Technique Tips. Dissection should be limited to the lateral
aspect of the greater trochanter (Fig. 27-24), without extending to the capsule or midportion of the femoral neck. Some
systems provide a small diameter, semiflexible tube that can
be inserted up to the fracture site after initial entry-site reaming. This tube is extremely valuable in manipulating the flexed,
abducted proximal fragment in proximal-third femur fractures.
Postoperative Management. Nails can be removed 9 to
18 months after radiographic union to prevent bony overgrowth
05/06/14 2:14 PM
A
B
Figure 27-22 AP (A) and lateral (B) radiographs immediately after internal fixation of the midshaft
femur fracture in a 13-year old with a pediatric locking nail that permits easy lateral entry, and requires
minimal reaming of the child’s proximal femur.
over the proximal tip of the nail. We do not routinely remove
locked antegrade nails from our teenage patients unless they are
symptomatic or request removal for another reason. Dynamization with removal of the proximal or distal screw generally is
not necessary.
A
LWBK1326-C27-p987-1026.indd 1008
Complications of Locked Intramedullary Nailing
Although good results have been reported with locked intramedullary nails and patient satisfaction is high, problems
with proximal femoral growth, osteonecrosis, and leg length
B
Figure 27-23 Preoperative (A) and postoperative
(B) images showing the use of a newer generation lateral entry nail to treat a proximal third femur fracture in
a 14-year-old girl.
05/06/14 2:14 PM
Lateral
epiphyseal a.
Safe starting point
for pediatric
antegrade nail
Lateral femoral
circumflex a.
Ligamentum
teres a.
Growth plate
Medial
circumflex a.
ANTERIOR
Femoral a.
POSTERIOR
Lateral femoral
circumflex a.
ANTERIOR
Figure 27-24 Trochanteric entry point for intramedullary nail indicated with arrow. Entry here with smaller diameter nails limits the
risk of AVN and ensures no awl in the piriformis fossa. (Reprinted
from Skaggs D, Flynn J. Trauma about the pelvis/hip/femur. Staying
Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott
Williams & Wilkins; 2006:109.)
discrepancy cannot be ignored. Fortunately, the osteonecrosis
rate with newer lateral trochanteric entry nails is lower.
In a series of intramedullary nailing of 31 fractures, Beaty
et al.12 reported one patient with segmental osteonecrosis of
the femoral head (Fig. 27-25), which was not seen on x-ray
until 15 months after injury. Kaweblum et al.106 reported a
patient with osteonecrosis of the proximal femoral epiphysis
after a greater trochanteric fracture, suggesting that the blood
supply to the proximal femur may have been compromised
by vascular disruption at the level of the greater trochanter
during rod insertion. Other researchers have reported single
patients with osteonecrosis of the femoral head after intramedullary nailing.141,158,196 A poll of the members of the Pediatric
Orthopaedic Society disclosed 14 patients with osteonecrosis
in approximately 1,600 femoral fractures. Despite the use of a
“safe” transtrochanteric insertion site for antegrade femoral rodding, a case of osteonecrosis has been reported. Buford et al.27
showed in their MRI study of hips after antegrade rodding that
subclinical osteonecrosis may be present. Antegrade rodding
through the trochanter or the upper end of the femur appears
to be associated with a risk of osteonecrosis in children with
open physes, regardless of chronologic age. Chung34 noted the
absence of transphyseal vessels to the proximal femoral epiphysis and demonstrated that the singular lateral ascending cervical artery predominantly supplies blood to the capital femoral
epiphysis (Fig. 27-26). He stated that all of the epiphyseal and
metaphyseal branches of the lateral ascending cervical artery
originate from a single stem that crosses the capsule at the trochanteric notch. Because the space between the trochanter and
A
B
Figure 27-25 A: Isolated femoral shaft fracture in an 11-year old. B: After fixation with an intramedullary nail, femoral head appears normal.
(continues)
LWBK1326-C27-p987-1026.indd 1009
05/06/14 2:14 PM
C
D
E
Figure 27-25 (continued) C: Eight months after injury, fracture is healed; note early signs of osteonecrosis of right femoral head. D: Fifteen months after injury, segmental osteonecrosis of the femoral
head is evident on x-rays. E: Magnetic resonance image shows extent of osteonecrosis of right femoral head. (D reprinted from Beaty JH, Austin SM, Warner WC, et al. Interlocking intramedullary nailing
of femoral-shaft fractures in adolescents: Preliminary results and complications. J Pediatr Orthop.
1994;14:178–183, with permission.)
the femoral head is extremely narrow, this single artery is vulnerable to injury and appears to be so until skeletal maturity,
regardless of chronologic age.
The proximal femoral physis is a continuous cartilaginous
plate between the greater trochanter and the proximal femur
in young children. Interference with the physis may result in
abnormal growth of the femoral neck, placing the child at a
small risk for subsequent femoral neck fracture.185 Antegrade
nailing with reaming of a large defect also may result in growth
disturbance in the proximal femur as well as femoral neck fracture (Fig. 27-27). Beaty et al.12 reported no “thinning” of the
femoral neck in their patients, which they attributed to an older
patient group (10 to 15 years of age) and design changes in
the femoral nail that allowed a decrease in the cross-sectional
diameter of the proximal portion of the femoral rods.
Plate Fixation for Femoral Shaft Fractures
Submuscular Bridge Plating
Submuscular bridge plating (Fig. 27-28)75,102 allows for stable
internal fixation with maintenance of vascularity to small fragments of bone, facilitating early healing.119
LWBK1326-C27-p987-1026.indd 1010
Modern techniques of femoral plating,176 limiting incisions,
maintaining the periosteum, and using long plates and filling
only a few select screw holes, have been adopted by many pediatric orthopedic trauma surgeons as a valuable tool to manage
length-unstable femur fractures. Pathologic fractures, especially
in the distal femoral metaphysis, create larger areas of bone
loss that can be treated with open biopsy, plate fixation, and
immediate bone grafting.
Kanlic et al.103 reported a series of 51 patients using
submuscular bridge plating with up to 10-year follow-up.
Fifty-five percent had unstable fracture patterns. There were
two significant complications: One plate breakage (3.5 mm)
and one fracture after plate removal. Functional outcome
was excellent with 8% significant leg length discrepancy.
Hedequist et al.74 reported on 32 patients aged 6 to 15 years
old. Most fractures in their series were comminuted, pathologic, osteopenic, or in a difficult location. Rozbruch et al.176
described modern techniques of plate fixation popularized
by the AO Association for the Study of Internal Fixation that
include indirect reduction, biologic approaches to internal
fixation, and greater use of blade plates and locked plates
(Fig. 27-29).
05/06/14 2:14 PM
Figure 27-26 The single ascending cervical artery (A) is the predominant blood supply to the femoral head. The vessel is at risk
during antegrade insertion of an intramedullary rod. (Reprinted from
Chung S. The arterial supply of the developing proximal end of the
femur. J Bone Joint Surg Am. 1976;58:961, with permission.)
Figure 27-27 Fifteen-year-old boy 3 years after intramedullary nailing of the right femur. Articulotrochanteric distance increased by
1.5 cm; note partial trochanteric epiphysiodesis (arrow) with mild
overgrowth of the femoral neck. (Reprinted from Beaty JH, Austin
SM, Warner WC, et al. Interlocking intramedullary nailing of femoral-shaft fractures in adolescents: Preliminary results and complications. Pediatr Orthop. 1994;14:178–183, with permission.)
A
B
Figure 27-28 AP (A) and lateral (B) radiographs showing a complex spiral distal femur fracture that
extends into the joint. This is a variation of Salter IV fracture.
LWBK1326-C27-p987-1026.indd 1011
(continues)
05/06/14 2:14 PM
C
Figure 27-28 (continued) C: The fracture was managed with submuscular plating, and percutaneous lag screw fixation of the distal
femoral condyle fractures.
A
B
Figure 27-29 A: This child with an unstable femoral fracture in
osteopenic bone was managed with a submuscular locking plate
providing alignment and stability. B: The lateral bow of the femur
may be partially preserved despite a straight plate.
LWBK1326-C27-p987-1026.indd 1012
Sink et al.186 reported on their center’s transition to treating unstable femur fractures with submuscular plating and
trochanteric entry nails, and reserving elastic nailing for stable
fractures. Their complication rate declined sharply with this
change in treatment philosophy.
In very rare situations, such as when there is limited bone
for fixation between the fracture and the physes, locked plating
techniques may be valuable. This technique provides greater
stability by securing the plate with a fixed-angle screw in which
the threads lock to the plate as well as in the bone. This effectively converts the screw-plate to a fixed-angle blade plate
device. In using this type of device, one should lock first, then
compress, and finally lock the plate on the opposite side of the
fracture. The locked plate can be used with an extensile exposure or with submuscular plating, but the latter is more difficult
and should only be attempted when the technique is mastered.
We do not routinely use locking plates unless pathologic
lesions, severe osteopenia, or severe comminution is present.
Locking screws can “cold weld” to the plate, later turning a
simple implant removal into a very difficult exercise involving
large exposures, cutting of the implant, and possibly locally
destructive maneuvers to remove the screws.
Technique: Submuscular Bridge Plating. The technique for
submuscular bridge plating of pediatric femur fractures has
been well described in recent publications.103,187,188 The patient
is positioned on a fracture table, and a provisional reduction
is obtained with gentle traction. In most cases, a 4.5-mm narrow, low-contact DCP plate is used. In osteopenic patients, or
when there is proximal or distal fracture, locking plates may
be used. A very long plate, with 10 to 16 holes, is preferred;
the plate selection is finalized by obtaining an image with the
plate over the anterior thigh, assuring that there are six screw
holes proximal and distal to the fracture (although in some
more proximal and distal fractures, only three holes will be
available). Depending on the fracture location and thus the
position of the plate, the plate will need to be contoured to
accommodate the proximal or distal femur. The table-top plate
bender is used to create a small flare proximally for the plate to
accommodate the contour of the greater trochanter, or a larger
flare to accommodate the distal femoral metaphysis. The plate
must be contoured anatomically, because the fixed femur will
come to assume the shape of the plate after screw fixation. A
2- to 3-cm incision is made over the distal femur, just above the
level of the physis. Exposure of the periosteum just below the
vastus lateralis facilitates the submuscular passage of the plate.
A Cobb elevator is used to dissect the plane between the periosteum and the vastus lateralis. The fracture site is not exposed,
and, in general, a proximal incision is not required. The plate is
inserted underneath the vastus lateralis, and the femoral shaft is
held to length by traction. The plate is advanced slowly, allowing the surgeon to feel the bone against the tip of the plate.
Fluoroscopy is helpful in determining proper positioning of the
plate. A bolster is placed under the thigh to help maintain sagittal alignment. Once the plate is in position and the femur is out
to length, a Kirschner wire is placed in the most proximal and
most distal hole of the plate to maintain length (Fig. 27-30).
Fluoroscopy is used to check the AP and lateral views and be
05/06/14 2:14 PM
A
B
Figure 27-30 A: A Kirschner wire is inserted in the end holes of the plate to maintain length. B: Drill
holes and screws are placed with fluoroscope imaging.
sure the bone is at appropriate length at this point. A third
Kirschner wire may be used to provide a more stable reduction
of the femoral shaft. Although screws can be used to facilitate
angular reduction to the plate, length must be achieved before
the initiation of fixation.
The principles of external fixation are used in choosing sites
for screw fixation. Greater spread of screws increases the stability of fracture fixation. We generally place one screw through
the distal incision under direct visualization. At the opposite
end of the femur, the next most proximal screw is placed to
fix length and provisionally improve alignment. Central screws
are then placed, using a free-hand technique with the “perfect
circle” alignment of the plate over the fracture fragments. Stab
holes are made centrally for drill and screw insertion. Rather
than using a depth gauge directly, because the bone will be
pulled to the plate, the depth gauge is placed over the thigh
itself to measure appropriate length of the screw. When screws
are inserted, a Vicryl tie is placed around the shank to avoid
losing the screw during percutaneous placement. Self-tapping
screws are required for this procedure. Six cortices are sought
on either side of the fracture.
The postoperative management includes protected weight
bearing on crutches with no need for cast immobilization, as
long as stable fixation is achieved. At times, there is benefit to
a knee immobilizer; however, in general, this is not required.
Early weight bearing in some series of plate fixation has resulted
in a low but significant incidence of plate breakage and non-
LWBK1326-C27-p987-1026.indd 1013
union. These complications should be decreased by a cautious
period of postoperative management.
There are occasional cases with sufficient osteopenia or
comminution to require a locked plate to provide secure fixation. In using a locked plate submuscularly, a large enough
incision must be used to be sure the bone is against the plate
when it is locked. The articular fragment is fixed first to ensure
that the angular relationship between the joint surface and the
shaft is perfect.
Complications of Plate Fixation
Refracture is rare at the end of the plate or through screw holes,
and whether bone atrophy under a plate is caused by stress shielding or by avascularity of the cortex is unknown. Although still
somewhat controversial, the plate and screws may be removed
at 1 year after fracture to avoid fracture at the end of the plate.
Plate removal can be difficult after submuscular plating; in
fact, the problems with plate removal keep some surgeons from
using the technique routinely. Pate et al.161 reviewed a series of
22 cases of plate removal after submuscular plating for femoral
shaft fracture. In 7 of the 22 cases, the incision and surgical
dissection was more extensive in the plate removal than in the
initial insertion. The authors alert the reader that bone can form
on the leading edge of the plate, complicating plate removal.
Quadriceps strength after plate fixation appears not to be
compromised,56 relative to intramedullary fixation or cast
immobilization.
05/06/14 2:14 PM
Author’s Preferred Treatment
Shaft Fractures
for
Femoral
For stable femur fractures in children under 6 months of age,
we use a Pavlik harness. Webril is gently wraped around the
thigh before placing the Pavlik. Abuse and metabolic bone disease must be considered in an infant with a femoral fracture.
If the fracture is unstable, usually the proximal fragment is
flexed and a Pavlik harness is the ideal device for reducing and
holding the fracture. The use of a Pavlik harness requires an
attentive and compliant caregiver. A Gore-Tex-lined spica is an
alternative, especially for the bigger, older baby. Traction with
a spica cast is rarely used if ever needed in this group.
For children 6 months to 5 years of age with an isolated
femoral fracture, an early spica cast is usually the treatment of
choice. In the typical low-energy toddler femur fracture, we
have noted similar clinical results, but much happier families
and children, when we use a one-leg “walking spica,” so this
has become our choice for this age group. Some children with
a walking spica benefit from cast wedging 1 to 2 weeks after
injury, so we prepare families for this possibility as we consent for the procedure. A Gore-Tex liner, if available, markedly
improves skin care. If length or alignment cannot be maintained
in an early spica cast (this is rare in low-energy fractures), traction followed by casting can be used. We typically use a distal
femoral traction pin and place the child in a 90/90 or oblique
position in the bed for traction. We must emphasize that over
95% of infants and toddlers can be managed without traction
with a low complication rate and low cost. In children with
multiple-system trauma, either flexible intramedullary nailing
or external fixation is often a better choice, based on the fracture anatomy and the soft tissue injury. Traction is very rarely
used in the setting of multiple-system trauma.
In children 5 to 11 years of age, retrograde flexible intramedullary nailing is generally the safest and best option for lengthstable fractures (and many length-unstable fractures). Submuscular bridge plating or external fixation is used for unstable fracture
patterns, comminuted fractures, and fractures with severe soft
tissue injury. Early spica casting may be used for nondisplaced or
minimally displaced fractures in this age group. In very large or
obese children (greater than 50 kg) who are 9 to 11 years of age,
we may use a small diameter locked trochanteric entry nail. In
certain situations, the family and surgeon prefer a “nonsurgical”
option; in such cases, spica casting, usually with traction, may be
used in these school-aged children.
In children 11 years to maturity, we generally prefer a trochanteric entry locked IM nail or submuscular bridge plating. Flexible intramedullary rods can be effective in this age
group (Fig. 27-31), especially for midshaft transverse fractures in petite teens. The surgeon should be aware that the
complication rate rises with flexible nailing in this older
group.148 External fixation is occasionally valuable in the 11- to
A, B
C
Figure 27-31 Successful use of titanium elastic nails in older teenager. This 15-year old sustained
a minimally displaced midshaft femur fracture A: AP and (B) lateral views at presentation. C: This
radiograph, taken 3 months after injury, shows that the fracture healed in perfect alignment with
abundant callous.
LWBK1326-C27-p987-1026.indd 1014
05/06/14 2:14 PM
16-year-old group, particularly in complex proximal or distal
fracture. Healing is slow, however, and the full treatment course
may take 4 months or more. Submuscular plating is also valuable
for subtrochanteric and supracondylar fractures of the femur,
whereas intramedullary nails are ideal for midshaft fractures.
If antegrade rodding is chosen, a transtrochanteric approach is
used. There is a limited role for retrograde-locked intramedullary nailing in adolescents approaching skeletal maturity.
Complications
of
Leg Length Discrepancy
The most common sequela after femoral shaft fractures in children is leg length discrepancy. The fractured femur may be initially short from overriding of the fragments at union; growth
acceleration occurs to “make up” the difference, but often this
acceleration continues and the injured leg ends up being longer. The potential for growth stimulation from femoral fractures
has long been recognized, but the exact cause of this phenomenon is still unknown. Growth acceleration has been attributed
to age, sex, fracture type, fracture level, handedness, and the
amount of overriding of the fracture fragments. Age seems to
be the most constant factor, but fractures in the proximal third
of the femur and oblique comminuted fractures also have been
associated with relatively greater growth acceleration.
Overgrowth and Shortening
Overgrowth after femoral fracture is most common in children
2 to 10 years of age. The average overgrowth is 0.9 cm, with
a range of 0.4 to 2.5 cm.183 Overgrowth occurs when the fracture is short, at length, or overpulled in traction at the time of
healing. In general, overgrowth occurs most rapidly during the
first 2 years after fracture and to a much lesser degree for the
next year or so.67 Because the average overgrowth after femoral
fracture is approximately 1 cm, shortening of 2 to 3 cm in the
cast is the maximal acceptable amount.
Truesdell203 first reported the phenomenon of overgrowth in
1921, and many researchers since have verified the existence of
growth stimulation after fracture.1,2,4,9,36,39,50,126,136,167 The relationship of the location of the fracture to growth is somewhat
controversial. Staheli192 and Malkawi et al.126 reported that
overgrowth was greatest if the fracture occurred in the proximal
third of the femur, whereas Henry83 stated that the most overgrowth occurred in fractures in the distal third of the femur.
Other investigators have found no relationship between fracture location and growth stimulation.50,83,170,183 The relationship
between fracture type and overgrowth also is controversial. In
general, most researchers believe that no specific relationship
exists between fracture type and overgrowth, but some have
reported overgrowth to be more frequent after spiral, oblique,
and comminuted fractures associated with greater trauma.
Angular remodeling occurs at the site of fracture, with appositional new bone formation in the concavity of the long bone.
Differential physeal growth also occurs in response to diaphyseal
angular deformity. Wallace and Hoffman210 stated that 74% of the
remodeling that occurs is physeal, and appositional remodeling
at the fracture site occurs to a much lesser degree. However, this
appears to be somewhat age dependent. It is clear that angular
remodeling occurs best in the direction of motion at the adjacent
joint.210 That is, anterior and posterior remodeling in the femur
occurs rapidly and with little residual deformity. In contrast,
remodeling of a varus or valgus deformity occurs more slowly.
The differential physeal growth in a varus or valgus direction in
the distal femur causes compensatory deformity, which is usually insignificant. In severe varus bowing, however, a hypoplastic
lateral condyle results, which may cause a distal femoral valgus
deformity if the varus bow is corrected.
Guidelines for acceptable alignment vary widely. The range
of acceptable anterior and posterior angulation varies from 30
to 40 degrees in children up to 2 years of age (Fig. 27-32),
decreasing to 10 degrees in older children and adolescents.125
The range of acceptable varus and valgus angulation also
becomes smaller with age. Varus angulation in infants and children should be limited to 10 to 15 degrees, although greater
degrees of angulation may have a satisfactory outcome. Acceptable valgus angulation is 20 to 30 degrees in infants, 15 to
20 degrees in children up to 5 years of age, and 10 degrees
in older children and adolescents. Compensation for deformity
around the knee is limited, so guidelines for the distal femoral
fractures should be stricter than proximal femoral fractures.
Late development of genu recurvatum deformity of the proximal tibia after femoral shaft fracture has been most often reported
as a complication of traction pin or wire placement through or
near the anterior aspect of the proximal tibial physis, excessive
traction, pin track infection, or prolonged cast immobilization.205
However, proximal tibial growth arrest may complicate femoral
shaft fracture, presumably as a result of occult injury.89 Femoral
pins are preferred for traction, but if tibial pins are required, the
proximal anterior tibial physis must be avoided.144 Femoral traction pins should be placed 1 or 2 fingerbreadths proximal to the
superior pole of the patella to avoid the distal femoral physis.
If significant angular deformity is present after fracture
union, corrective osteotomy should be delayed for at least a
year unless the deformity is severe enough to markedly impair
function. This will allow determination of remodeling potential
before deciding that surgical correction is necessary. The ideal
osteotomy corrects the deformity at the site of fracture. In juvenile patients, however, metaphyseal osteotomy of the proximal
or distal femur may be necessary. In adolescents with midshaft
deformities, diaphyseal osteotomy and fixation with an interlocking intramedullary nail are often preferable.
Distal femoral angular malunion is being recognized after
submuscular plating. Care in plate contouring and postoperative monitoring are recommended.
Angular Deformity
Rotational Deformity
Some degree of angular deformity is frequent after femoral shaft
fractures in children, but this usually remodels with growth.
According to Verbeek,206 rotational deformities of 10 degrees
to more than 30 degrees occur in one-third of children after
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cm
Figure 27-32 Remodeling potential of the femur during infancy. This infant sustained a femoral
fracture during a breech delivery and was placed in a spica cast but with insufficient flexion of the
hip. Left: At 3 weeks, union is evident with about 45 degrees of angulation in the sagittal plane and
1.5 cm of overriding. Center: Line drawing demonstrating true angulation. Right: Twelve months
later the anterior angulation has reduced to a level such that it was not apparent to the family, and the
shortening has reduced to less than 1 cm.
conservative treatment of femoral shaft fractures. Malkawi
et al.126 found asymptomatic rotational deformities of less
than 10 degrees in two-thirds of their 31 patients. Salem and
Keppler179 noted a 47% incidence of torsional malunion ≥15
degrees in the patients they treated with elastic nails at one
center in Germany. Torsional deformity usually is expressed as
increased femoral anteversion on the fractured side compared
with the opposite side, as demonstrated by physical examination; a difference of more than 10 degrees has been the criterion
of significant deformity. However, Brouwer et al.23 challenged
this criterion, citing differences of 0 to 15 degrees in a control
group of 100 normal volunteers. The accuracy of measurements from plain x-rays also has been disputed, and Norbeck
et al.155 suggested the use of computed tomographic (CT) scanning for greater accuracy.
Rotational remodeling in childhood femoral fractures is
another controversy in the search for criteria on which to
base therapeutic judgments. According to Davids44 and Braten
et al.22 up to 25 degrees of rotational malalignment at the time
of healing of femoral fractures appears to be well tolerated in
children. In their patients with more than 25 degrees of rotational malalignment, however, deformity caused clinical complaints. Davids44 found no spontaneous correction in his study
LWBK1326-C27-p987-1026.indd 1016
of malunions based on CT measurements, but the length of
follow-up is insufficient to state that no rotational remodeling
occurs. Brouwer et al.23 and others15,72,157,206 reported slow rotational correction over time. Buchholz et al.26 documented five
children with increased femoral anteversion of 10 degrees or
more after fracture healing in children between 3 and 6 years
old. In three of five children there was full correction of the
rotational deformity but the oldest of the children failed to correct spontaneously.
Certainly, in older adolescents, no significant rotational
remodeling will occur. In infants and juveniles, some rotational deformity can be accepted55 because either true rotational remodeling or functional adaptation allows resumption
of normal gait. Up to 30 degrees of malrotation in the femur
should result in no functional impairment unless there is preexisting rotational malalignment. The goal, however, should
be to reduce a rotational deformity to 10 degrees, based on
alignment of the proximal and distal femur radiographically,
interpretation of skin and soft tissue envelope alignment, and
correct positioning within a cast, based on the muscle pull on
the proximal fragment. The distal fragment should be lined up
with the position of the proximal fragment determined by the
muscles inserted upon it (Fig. 27-3).
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Delayed Union
Delayed union of femoral shaft fractures is uncommon in children. The rate of healing also is related to soft tissue injury and
type of treatment. The time to fracture union in most children
is rapid and age dependent. In infants, fracture can be healed in
a 2 to 3 weeks. In children under 5 years of age, healing usually
occurs in 4 to 6 weeks. In children 5 to 10 years of age, fracture
healing is somewhat slower, requiring 8 to 10 weeks. Throughout adolescence, the time to healing continues to lengthen. By
the age of 15 years, the mean time to healing is about 13 weeks,
with a range from 10 to 15 weeks (Fig. 27-33). Application
of an external fixation device appears to delay callus formation and slow the rate of healing. Flexible nailing allows some
motion at the fracture site, promoting extensive callus formation. Bone grafting and internal fixation with either a compression plate or locked intramedullary nail is the usual treatment
for delayed union in older children and adolescents. Delayed
union of a femoral fracture treated with casting in a child 1 to
6 years of age is probably best treated by continuing cast immobilization until bridging callus forms or (rarely) by additional
bone grafting.
Nonunion
Nonunions of pediatric femoral fractures are rare.118 They tend
to occur in adolescents, in infected fractures, or in fractures with
segmental bone loss or severe soft tissue loss. Tibial fractures
are the most common source of pediatric nonunions; femoral
fractures account for only 15% of nonunions in children. Even
in segmental fractures with bone loss, young children may have
sufficient osteogenic potential to fill in a significant fracture gap
(Fig. 27-34).140 For the rare femoral shaft nonunion in a child
Figure 27-34 The effectiveness of remodeling of the femur in
a child. Left: Comminuted fracture in an 8-year-old child managed
with a femoral pin incorporated in a spica cast. The midfragment is
markedly angulated. Center: Fracture after union 12 weeks later
with filling in of the defect and early absorption of the protruding
fragment. Right: Appearance at age 12 with only a minimal degree
of irregularity of the upper femur remaining.
Time to union (wks)
5 to 10 years of age, bone grafting and plate-and-screw fixation
have been traditional treatment methods, but more recently
insertion of an interlocking intramedullary nail and bone
grafting have been preferred, especially in children over 10 to
12 years of age. Aksoy et al.3 reported a small series of nonunions in malunions salvaged with titanium elastic nails. Union
was achieved in 6 to 9 months in most cases.
Robertson et al.173 reported the use of external fixators in 11
open femoral fractures. The time to union was delayed, but a
satisfactory outcome occurred without subsequent procedures.
This supports the belief that the rates of delayed union and
nonunion are low in pediatric femoral fractures, because open
fractures would have the highest rates of delayed union.
Muscle Weakness
Age (y)
*Excludes delayed unions and pseudoarthorses.
Figure 27-33 Time required for union of femoral shaft fractures
in childhood and adolescence. (Redrawn from Skak SV, Jensen
TT. Femoral shaft fracture in 265 children. Acta Orthop Scand.
1988;59:704–707, with permission.)
LWBK1326-C27-p987-1026.indd 1017
Weakness after femoral fracture has been described in the hip
abductor musculature, quadriceps, and hamstrings, but persistent weakness in some or all of these muscle groups seldom
causes a long-term functional problem. Hennrikus et al.82
found that quadriceps strength was decreased in 30% of his
patients and 18% had a significant decrease demonstrated by
a one-leg hop test. Thigh atrophy of 1 cm was present in 42%
05/06/14 2:14 PM
of patients. These deficits appeared to be primarily related to
the degree of initial displacement of the fracture. Finsen et al.56
found hamstring and quadriceps deficits in patients with femoral shaft fractures treated with either rods or plates.
Damholt and Zdravkovic43 documented quadriceps weakness in approximately one-third of patients with femoral fractures, and Viljanto et al.207 reported that this weakness was
present when patients were treated operatively or nonoperatively. Biyani et al.17 found that hip abductor weakness was
related to ipsilateral fracture magnitude, long intramedullary
rods, and, to a lesser degree, heterotopic ossification from intramedullary rodding. Hedin and Larsson76 found no significant
weakness in any of 31 patients treated with external fixation
for femoral fractures based on either Cybex testing or a one-leg
hop test. He felt that the weakness seen in other studies may be
related to prolonged immobilization.
Injury to the quadriceps muscle probably occurs at the time
of femoral fracture, and long-term muscle deficits may persist in
some patients regardless of treatment. Severe scarring and contracture of the quadriceps occasionally require quadricepsplasty.94
Infection
Infection may rarely complicate a closed femoral shaft fracture,
with hematogenous seeding of the hematoma and subsequent
osteomyelitis. Fever is commonly associated with femoral fractures during the first week after injury,193 but persistent fever
or fever that spikes exceedingly high may be an indication of
infection. One should have a high index of suspicion for infection in type III open femur fractures. A series of 44 open femur
fractures93 reported no infection in type I and II fractures, but
a 50% (5 of 10) of type III fractures developed osteomyelitis.
Presumably this occurs because of the massive soft tissue damage accompanying this injury.
Pin track infections occasionally occur with the use of skeletal
traction, but most are superficial infections that resolve with local
wound care and antibiotic therapy. Occasionally, however, the
infections may lead to osteomyelitis of the femoral metaphysis or
a ring sequestrum that requires surgical debridement.
Neurovascular Injury
Nerve and vascular injuries are uncommonly associated with
femoral fractures in children.46,99,175,193 An estimated 1.3% of
femoral fractures in children are accompanied by vascular
injury46,99,175,193 such as intimal tears, total disruptions, or injuries resulting in the formation of pseudoaneurysms.181 Vascular injury occurs most frequently with displaced Salter–Harris
physeal fractures of the distal femur or distal femoral metaphyseal fractures. If arteriography indicates that vascular repair
is necessary after femoral shaft fracture, open reduction with
internal fixation or external fixation of the fracture is usually
recommended first to stabilize the fracture and prevent injury
of the repair. Secondary limb ischemia also has been reported
after the use of both skin and skeletal traction. Documentation of peripheral pulses at the time of presentation, as well as
throughout treatment, is necessary.
Nerve abnormalities reported with femoral fractures in children include those caused by direct trauma to the sciatic or
LWBK1326-C27-p987-1026.indd 1018
femoral nerve at the time of fracture and injuries to the peroneal nerve during treatment. Weiss et al.211 reported peroneal
nerve palsies in 4 of 110 children with femoral fractures treated
with early 90/90 hip spica casting. They recommended extending the initial short leg portion of the cast above the knee to
decrease tension on the peroneal nerve.
Riew et al.172 reported eight nerve palsies in 35 consecutive
patients treated with locked intramedullary rodding. The nerve
injuries were associated with delay in treatment, preoperative
shortening, and boot traction. Resolution occurred in less than
1 week in six of eight patients.
Many peroneal nerve deficits after pediatric femoral shaft
fractures will resolve with time. In infants, however, the development of an early contracture of the Achilles tendon is more
likely. Because of the rapid growth in younger children, this
contracture can develop quite early; if peroneal nerve injury is
suspected, an ankle-foot orthosis should be used until the peroneal nerve recovers. If peroneal, femoral, or sciatic nerve deficit
is present at initial evaluation of a closed fracture, no exploration is indicated. If a nerve deficit occurs during reduction or
treatment, the nerve should be explored. Persistent nerve loss
without recovery over a 4- to 6-month period is an indication
for exploration.
Compartment Syndrome
Compartment syndromes of the thigh musculature are rare,
but have been reported in patients with massive thigh swelling
after femoral fracture and in patients treated with intramedullary rod fixation.142 If massive swelling of thigh musculature
occurs and pain is out of proportion to that expected from a
femoral fracture, compartment pressure measurements should
be obtained and decompression by fasciotomy should be considered. It is probable that some patients with quadriceps fibrosis170 and quadriceps weakness41,198 after femoral fracture had
intracompartmental pressure phenomenon. Mathews et al.130
reported two cases of compartment syndrome in the “well leg”
occurring when the patient was positioned for femoral nailing
in the hemilithotomy position. Vascular insufficiency related to
Bryant traction may produce signs of compartment syndrome
with muscle ischemia.36 Janzing et al.100 reported the occurrence of compartment syndrome using skin traction for treatment of femoral fractures. Skin traction has been associated
with compartment syndrome in the lower leg in both the fractured and nonfractured sides. It is important to realize that in
a traumatized limb, circumferential traction needs to be monitored closely and is contraindicated in the multiply injured or
head-injured child. As noted in the spica cast section, several
cases of leg compartment syndrome have been reported after
spica cast treatment in younger children with femur fractures.
Special Fractures
of the
Femoral Shaft
Subtrochanteric Fractures
Subtrochanteric fractures generally heal slowly, angulate into
varus, and are more prone to overgrowth. These fractures offer
a challenge, as the bone available between the fracture site and
the femoral neck limits internal fixation options. In younger
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Supracondylar Fractures
A
B
Figure 27-35 A, B: The combination of anterograde and retrograde titanium elastic nail insertion is a good solution for the proximal femur fracture.
children, traction and casting can be successful.47 Three weeks
of traction is usually necessary, and the surgeon should place
a good valgus mold at the fracture site, and monitor the fracture closely in the first 2 weeks after casting. When the patient
returns for follow-up and the subtrochanteric fracture has
slipped into varus malangulation, the cast can be wedged in
clinic or casting can be abandoned for another method. Parents
should be warned that loss of reduction in the cast is quite common, and wedging in clinic is a routine step in management.
An external fixation strategy can be quite successful if there is
satisfactory room proximally to place pins. Once there is satisfactory callus (about 6 weeks), the fixator can be removed and
the weight bearing allowed in a walking spica (long leg cast
with a pelvic band—place a valgus mold to stabilize fracture
in the first few weeks after external fixator removal). Flexible
nailing can be used, with a proximal and distal entry strategy
(Fig. 27-35). A pitfall in this fracture is thinking the proximal
fragment is too short to use flexible IM nails on the AP radiograph because the proximal fragment is pulled into flexion by
the unopposed psoas muscle. Pombo and Shilt163 reported a
series of 13 children, averaging of 8 years old with subtrochanteric fractures, treated with flexible nailing. Results were
excellent or satisfactory in all cases. Submuscular plating can
also produce satisfactory results.98 In adolescents, there is insufficient experience with this fracture to determine at what age
intramedullary fixation with a reconstruction-type nail and an
angled transfixion screw into the femoral neck is indicated.
Antegrade intramedullary nail systems place significant holes
in the upper femoral neck and should be avoided. Unlike subtrochanteric fractures in adults, nonunions are rare in children
with any treatment method.
LWBK1326-C27-p987-1026.indd 1019
Supracondylar fractures represent as many as 12% of femoral
shaft fractures190 and are difficult to treat because the gastrocnemius muscle inserts just above the femoral condyles and pulls
the distal fragment into a position of extension (Fig. 27-36),70
making alignment difficult (Fig. 27-3). The traditional methods of casting and single-pin traction may be satisfactory in
young children (Fig. 27-37). As mentioned in the external fixation section above, supracondylar fractures through a benign
lesion are safely and efficiently treated with a brief period (4 to
6 weeks) of external fixation (Fig. 27-38), followed by a walking cast until the callus is solid and the pin sites are healed. In
other cases, internal fixation is preferable, either with submuscular plating (Figs. 27-28 and 27-39) and fully threaded cancellous screws (if there is sufficient metaphyseal length) or with
crossed smooth K-wires transfixing the fracture from the epiphysis to the metaphysis, as described for distal femoral physeal
separations.182 If there is sufficient metaphyseal length, flexible
nailing can be used, so long as fixation is satisfactory. The flexible nails can be either placed antegrade as originally described,
or a retrograde if there is satisfactory distal bone for fixation
near the nail entry site. Biomechanically, retrograde insertion is
superior.138 Pathologic fractures in this area are common, and
an underlying lesion should always be sought.
Open Femoral Fractures
Open femoral fractures are uncommon in children because of
the large soft tissue compartment around the femur. Proper
wound care, debridement, stabilization, and antibiotic therapy
are required to reduce the chance of infection.70 In a study by
Hutchins et al.,93 70% of children with open femoral fractures
had associated injuries and 90% were automobile related. The
average time to healing was 17 weeks, and 50% of the Gustilo
type III injuries developed osteomyelitis.
External fixation of open femoral shaft fractures simplifies
wound care and allows early mobilization. The configuration
of the external fixator is determined by the child’s size and the
fracture pattern. Generally, monolateral half-pin frames are
satisfactory, but thin-wire circular frames may be necessary if
(text continues on page 1022)
Figure 27-36 It is difficult to treat distal femoral shaft fractures in
traction. The muscle forces around the knee often result in significant flexion at the fracture site.
05/06/14 2:14 PM
A
C
B
D
Figure 27-37 A: This 6-year-old patient sustained an unstable supracondylar fracture of the femur.
B: The fracture was managed with immediate spica casting with the knee in 90 degrees of flexion,
mandatory in such a case to prevent posterior angulation. Bayonet apposition, as shown in this figure
(C: lateral and D: AP) is acceptable in a child of this age.
LWBK1326-C27-p987-1026.indd 1020
05/06/14 2:14 PM
A
B
C
D
Figure 27-38 AP (A) and lateral (B) radiographs showing a fracture at the junction of the distal femoral metaphysis and diaphysis. C: The fractures reduced into near-anatomic alignment and an external
fixator was used to control the distal fragment. D: The fixator was removed 8 weeks after injury, and
after a brief period of weight bearing is tolerated a long leg cast, the fracture has healed in anatomic
alignment with no shortening.
LWBK1326-C27-p987-1026.indd 1021
05/06/14 2:14 PM
A
bone loss is extensive. External fixation provides good fracture
control, but, as always, family cooperation is required to manage pin and fixator care.
Plate fixation also allows early mobilization as well as anatomic reduction of the femoral fracture. Wound care and
treatment of other injuries are made easier in children with
multiple trauma. However, this is an invasive technique with
the potential for infection and additional injury to the already
traumatized soft tissues in the area of the fracture. In emergency situations, plate fixation or intramedullary fixation may
be used for Gustilo–Anderson type I and II fractures; type III
fractures in older adolescents are better suited for external fixation or intramedullary nailing. Plate breakage can occur if bone
grafting is not used for severe medial cortex comminution.
In older adolescents, submuscular plating or trochanteric
entry nailing is often the optimal treatment choice. Closed
nailing after irrigation and drainage of the fracture allows early
mobilization and easy wound care in patients with Gustilo–
Anderson type I, II, IIIA, and IIIB injuries, but the risk of osteonecrosis must be recognized.
Femoral Fractures in Patients with
Metabolic or Neuromuscular Disorders
For patients with osteogenesis imperfecta who have potential
for ambulation, surgical treatment with Rush, Bailey–Dubow, or
Fassier rods (see Chapter 8) is recommended for repeated fractures or angular deformity. Cast immobilization is minimized
in patients with myelomeningocele or cerebral palsy, because of
the frequency of osteoporosis and refracture in these patients.
If possible, existing leg braces are modified for treatment of the
LWBK1326-C27-p987-1026.indd 1022
B
Figure 27-39 Preoperative (A) and postoperative (B) x-rays showing a fracture at the
junction of the distal femoral metaphysis and
diaphysis treated with plate fixation.
femoral fracture. In nonambulatory patients, a simple pillow
splint is used.
Floating Knee Injuries
These rare injuries occur when ipsilateral fractures of the femoral
and tibial shafts leave the knee joint “floating” without distal or
proximal bony attachments. They are high-velocity injuries, usually resulting from collision between a child pedestrian or cyclist
and a motor vehicle. Most children with floating knee injuries
have multiple-system trauma, including severe soft tissue damage, open fractures, and head, chest, or abdominal injuries.
Except in very young children, it is usually best to fix both
fractures. If both fractures are open, external fixation of both
the tibial and femoral fractures may be appropriate. If immediate mobilization is necessary, fixation of both fractures with
external fixation, intramedullary nails, compression plates, or
any combination of these may be indicated.
Letts et al.116 described five patterns of ipsilateral tibial and
femoral fractures and made treatment recommendations based
on those patterns (Fig. 27-40). Because of the high prevalence
of complications after closed treatment, Bohn and Durbin19 recommended open or closed reduction and internal fixation of
the femoral fracture in older children. Arslan et al.7 evaluated
the treatment of the “floating knee” in 29 consecutive cases,
finding that those treated operatively had a shorter hospital
stay, decreased time to weight bearing, and fewer complications than those managed with splinting casting or traction.
Arslan et al.7 demonstrated that open knee fracture rather than
ligamentous injury was a risk factor for poor outcome and that
angulation was a predictor of future compromise of function.
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Figure 27-40 Classification of floating knee
injuries in children. (Redrawn from Letts M,
Vincent N, Gouw G. The “floating knee” in children. J Bone Joint Surg Br. 1986;68:442, with
permission.)
Bohn and Durbin19 reported that of 19 patients with floating knee injuries, at long-term follow-up 11 had limb length
discrepancy secondary to either overgrowth of the bone after
the fracture or premature closure of the ipsilateral physis (seven
patients), genu valgum associated with fracture of the proximal tibial metaphysis (three patients), or physeal arrest (one
patient). Four patients had late diagnosis of ligamentous laxity of the knee that required operation. Other complications
included peroneal nerve palsy, infection, nonunion, malunion,
and refracture.
Fractures in the Multiple-System
Trauma Patient
In a study of 387 previously healthy children with femoral
fractures, the authors evaluated the effect of stabilization on
pulmonary function. Patients with severe head trauma or cervical spine trauma are at greatest risk for pulmonary complications. Timing of treatment of femoral fractures appears to not
affect the prevalence of pulmonary complications in children.
Mendelson et al.139 similarly showed no effect of timing of femoral fixation on long-term outcome but early fracture fixation
did decrease hospital stay without increasing the risk of central
nervous system or pulmonary complications.
LWBK1326-C27-p987-1026.indd 1023
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FEMORAL SHAFT FRACTURES

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