fracture of femur in children

1. FEMORAL FRACTURESFEMORAL FRACTURES
IN CHILDRENIN CHILDREN
Dr.Mohammed saleem khanDr.Mohammed saleem khan

2. Anatomy and DevelopmentAnatomy and Development
 Femur first appears during fourth week ofFemur first appears during fourth week of
gestation by mesenchymal tissuegestation by mesenchymal tissue
 Primary ossification center is femoral shaftPrimary ossification center is femoral shaft
 Secondary center begins at upperSecondary center begins at upper
epiphysis at 6 month that latter becomesepiphysis at 6 month that latter becomes
the femoral head and greater trochantorthe femoral head and greater trochantor
 Distal secondary center begins at 7 monthDistal secondary center begins at 7 month

3. Anatomy and DevelopmentAnatomy and Development
 Femoral head ossifies at 4-5 month of postFemoral head ossifies at 4-5 month of post
gestational agegestational age
 Greater trochanter ossifies at 4 year of ageGreater trochanter ossifies at 4 year of age
 Lessor trochantor ossifies at 10 year of ageLessor trochantor ossifies at 10 year of age
 Woven bone results from this ossification andWoven bone results from this ossification and
persists for first eighteen months of lifepersists for first eighteen months of life
 Lattor becoming more adult type lamellarLattor becoming more adult type lamellar
bone,increase in diameter and area of bonebone,increase in diameter and area of bone
leads increase in strength of boneleads increase in strength of bone

4. Anatomy and developmentAnatomy and development
 Proximal femoral physis- 30% ofProximal femoral physis- 30% of
longitudinal growthlongitudinal growth
 Distal femoral physis- 70% of longitudinalDistal femoral physis- 70% of longitudinal
growthgrowth
 Trochanteric apophysis- most ofTrochanteric apophysis- most of
trochanteric growth appositional after agetrochanteric growth appositional after age
8 years8 years

5. Mechanism of injuryMechanism of injury
 Child abuseChild abuse
 High energy injury like motor vehicle accidentHigh energy injury like motor vehicle accident
 Gunshot woundGunshot wound
 Pathological fracture (uncommon)as inPathological fracture (uncommon)as in
osteogenesis imperfectaosteogenesis imperfecta
 Benign lesions such as non ossifyingBenign lesions such as non ossifying
fibroma,aneurysmal bone cystfibroma,aneurysmal bone cyst
 Stress fractures (upto 4%)Stress fractures (upto 4%)

6. DiagnosisDiagnosis
 Extreme painExtreme pain
 Unable to walkUnable to walk
 Obvious fractureObvious fracture
 SwellingSwelling
 InstabilityInstability
 CrepitanceCrepitance
 TendernessTenderness

7. Wadell’s triadWadell’s triad
 Femoral fractureFemoral fracture
 Intra thoracic or intra abdominal injuryIntra thoracic or intra abdominal injury
 Head injuryHead injury
Asossiated with high energy injuryAsossiated with high energy injury
Hence entire child must be examinedHence entire child must be examined

8. Associated injuriesAssociated injuries
 Fracture shaft of femur may be associatedFracture shaft of femur may be associated
with intertroch or fracture neck of femurwith intertroch or fracture neck of femur
 Distal fracture may be assosiated withDistal fracture may be assosiated with
physeal injury around knee,knee ligamentphyseal injury around knee,knee ligament
injury,meniscal injury.injury,meniscal injury.
 Hence x-ray should be done with bothHence x-ray should be done with both
joints and with both AP & Lateral viewsjoints and with both AP & Lateral views

9. ClassificationClassification
 Open or closedOpen or closed
 Location of fracture- subtrochanteric,Location of fracture- subtrochanteric,
diaphyseal (proximal, mid, distal third),diaphyseal (proximal, mid, distal third),
supracondylarsupracondylar
 Fracture pattern- transverse, spiral, oblique,Fracture pattern- transverse, spiral, oblique,
comminuted, greenstickcomminuted, greenstick
 Amount of shorteningAmount of shortening
 Angular deformityAngular deformity

10. ClassificationClassification
 Open fractures are classified according toOpen fractures are classified according to
Gustillo system.Gustillo system.
 Most common is simple transverseMost common is simple transverse
closedclosed non comminutednon comminuted..

11. Position with relation of Fx levelPosition with relation of Fx level
 In proximal shaft fracture proximalIn proximal shaft fracture proximal
segment assumes Flexion(iliopsoas)segment assumes Flexion(iliopsoas)
 Abduction(abductor muscle group)Abduction(abductor muscle group)
 Lateral rotation(external rotators)Lateral rotation(external rotators)

12. Position with relation of Fx levelPosition with relation of Fx level
 In mid shaft fracture effect is less extremeIn mid shaft fracture effect is less extreme
due to compensation by adductors &due to compensation by adductors &
extensors attatchment on proximalextensors attatchment on proximal
segmentsegment
 Little is the alteration in distal fracturesLittle is the alteration in distal fractures
 In supracondylar fractures,hyperextentionIn supracondylar fractures,hyperextention
of distal fragmentof distal fragment

13. TREATMENTTREATMENT

14. SpectrumSpectrum
No one correct method for
treatment

15. ConsiderationsConsiderations
 Involve the parents in decisionsInvolve the parents in decisions
 Remember the effects on the familyRemember the effects on the family
 Risk/Benefit ratio is different in childrenRisk/Benefit ratio is different in children
Growth and Remodeling potentialGrowth and Remodeling potential
Tolerate immobilization betterTolerate immobilization better
 Assess for intentional injury (child abuse)Assess for intentional injury (child abuse)
Especially child < 3 yoEspecially child < 3 yo

16. GoalsGoals
 Symmetric length and alignment at theSymmetric length and alignment at the
end of treatment and growthend of treatment and growth
 Minimal disruption of patient’s life andMinimal disruption of patient’s life and
developmentdevelopment
 Treatment should :Treatment should :
be simple and effectivebe simple and effective
Allow maximum mobilityAllow maximum mobility
Avoid disastrous complicationsAvoid disastrous complications

17. Treatment Options for Femoral Shaft Fractures in Children and AdolescentsTreatment Options for Femoral Shaft Fractures in Children and Adolescents
AgeAge TreatmentTreatment
Birth to 24 moBirth to 24 mo Pavlik harness (newborn to 6 mo)Pavlik harness (newborn to 6 mo)
Immediate spica castImmediate spica cast
Traction & spica castTraction & spica cast
24 mo to 5 yr24 mo to 5 yr Immediate spica castImmediate spica cast
Traction & spica castTraction & spica cast
External fixation (rare)External fixation (rare)
Flexible intramedullary rod (rare)Flexible intramedullary rod (rare)
6-11 yr6-11 yr Traction & spica castTraction & spica cast
Flexible intramedullary rodFlexible intramedullary rod
Compression plateCompression plate
External fixationExternal fixation
12 yr to maturity12 yr to maturity Flexible intramedullary rodFlexible intramedullary rod
Compression plateCompression plate
Locked intramedullary rodLocked intramedullary rod
External fixationExternal fixation
Treatment choices are influenced by polytrauma (vs. an isolated femoral shaftTreatment choices are influenced by polytrauma (vs. an isolated femoral shaft
fracture) or open fractures with soft tissue traumafracture) or open fractures with soft tissue trauma

18. Immediate or Early Spica Cast-Immediate or Early Spica Cast-
Ideal PatientIdeal Patient
 Less than 5 years oldLess than 5 years old
 Less than 100 lbsLess than 100 lbs
 Initial shortening <2 cmInitial shortening <2 cm
 Isolated injuryIsolated injury
 Note -Spica casts used for decades andNote -Spica casts used for decades and
can work for almost any pediatric femurcan work for almost any pediatric femur
fracturefracture

19. ContraindicationsContraindications
 Massive swelling of thighMassive swelling of thigh
 Associated injuries are presentAssociated injuries are present
 Shortening > 2 cmShortening > 2 cm

20. Immediate Spica CastImmediate Spica Cast
 X-ray weekly for 3 weeksX-ray weekly for 3 weeks
 Time in spica = age in years + 3 weeks upTime in spica = age in years + 3 weeks up
to maximum 8 weeksto maximum 8 weeks
 Wedge cast for malalignmentWedge cast for malalignment
 Rotational alignment important at initialRotational alignment important at initial
cast applicationcast application

21. ComplicationsComplications
 Leg length discrepancyLeg length discrepancy
ShorteningShortening
OvergrowthOvergrowth
 MalunionMalunion
 Cast soreCast sore
 Peroneal PalsyPeroneal Palsy
 Compartment syndromeCompartment syndrome

22. Compartment Syndrome ComplicatingCompartment Syndrome Complicating
Early Spica Cast Treatment ofEarly Spica Cast Treatment of
Isolated Femoral Shaft Fractures in ChildrenIsolated Femoral Shaft Fractures in Children

23. Problem casesProblem cases
 Older or larger (obese) childrenOlder or larger (obese) children
 Multiple injury – head, chest, abdomenMultiple injury – head, chest, abdomen
 Multiple fracture – floating kneeMultiple fracture – floating knee
 Open fracture, burn, deglovingOpen fracture, burn, degloving
 High energy, very unstable fracturesHigh energy, very unstable fractures
 Proximal and distal 1/3 fracturesProximal and distal 1/3 fractures

24. 11 years old
70 kilograms

25. Acceptable angulationAcceptable angulation
AgeAge Varus/Varus/
valgusvalgus
Anterior/Anterior/
posteriorposterior
ShorteningShortening
(mm)(mm)
Birth-Birth-
2 yr.2 yr.
3030 3030 1515
2-5yr2-5yr 1515 2020 2020
6-116-11 1010 1515 1515
11-11-
maturitymaturity
55 1010 1010

26. Traction & castingTraction & casting
 Indications for tractionIndications for traction
 Unstable femoral fracture in child<6 yr ofUnstable femoral fracture in child<6 yr of
age & shortening> 2-3 cmage & shortening> 2-3 cm
 Femoral fracture that fails to maintainFemoral fracture that fails to maintain
proper length & allignment in a spica castproper length & allignment in a spica cast
 Femoral fracturte in children 6-11 yr of ageFemoral fracturte in children 6-11 yr of age
without associated injurieswithout associated injuries

27. TractionTraction
 Bryant tractionBryant traction
 Hip 90 degree flexedHip 90 degree flexed
& knee extended& knee extended
 Recommended inRecommended in
infants<2 yr age &infants<2 yr age &
<20 lb weight<20 lb weight
 Modified bryant,kneeModified bryant,knee
is flexed to 45 degreeis flexed to 45 degree
 Simple hoizontalSimple hoizontal
tractiontraction

28. TractionTraction
 Limitations of skin tractionLimitations of skin traction
 Slough and blistering of skinSlough and blistering of skin
 When more than 5 lb weight is requiredWhen more than 5 lb weight is required
 In older childrenIn older children

29. Skeletal tractionSkeletal traction
 Distal femur is the location of choice forDistal femur is the location of choice for
traction pintraction pin
 Should be placed at right angle to shaft toShould be placed at right angle to shaft to
prevent angulation at fracture siteprevent angulation at fracture site
 Growth arrest in proximal tibial physis &Growth arrest in proximal tibial physis &
subsequent recurvatum deformity aresubsequent recurvatum deformity are
often associated with proximal tibial pinoften associated with proximal tibial pin
 90/90 traction is being used90/90 traction is being used
 Oblique traction,hip flexed 20-60 degreeOblique traction,hip flexed 20-60 degree

31. TractionTraction
 Traction is applied for an average of aboutTraction is applied for an average of about
3 weeks and when there is callus3 weeks and when there is callus
formation on x ray spica cast is appliedformation on x ray spica cast is applied
 Cast is applied for an average of about 8Cast is applied for an average of about 8
weeksweeks

32. Hip spica castHip spica cast
Position of knee &hip is controversial inPosition of knee &hip is controversial in
spica castspica cast
More proximal is the fracture more will beMore proximal is the fracture more will be
the flexion at hip jointthe flexion at hip joint
there is about 30 degree abduction onthere is about 30 degree abduction on
either side of legeither side of leg

33. Early “Sitting” SpicaEarly “Sitting” Spica
Fibreglass is stronger

34. Early Sitting Spica –Early Sitting Spica –
3 Part, Below Knee Cast First3 Part, Below Knee Cast First
Method, 90-90 PositionMethod, 90-90 Position

35. Current Technique –Current Technique –
Above knee cast (thigh and leg) first.Above knee cast (thigh and leg) first.
Hip and knee- 40-45 flexion, foot out.Hip and knee- 40-45 flexion, foot out.
Can include opposite thigh if desired.Can include opposite thigh if desired.
Unilateral spica cast effective for low energy fractures

36. Surgical OptionsSurgical Options
 Plate & screw fixationPlate & screw fixation
 External fixationExternal fixation
 Flexible nailingFlexible nailing
 Rigid nailingRigid nailing

37. ORIF with Plates/ScrewsORIF with Plates/Screws
 Advantages – rigid, technique familiar toAdvantages – rigid, technique familiar to
most surgeons, allows early motion,most surgeons, allows early motion,
favorable results reported in children withfavorable results reported in children with
associated head injuriesassociated head injuries
 Disadvantages- large scar, possibleDisadvantages- large scar, possible
refracture after plate removed, higherrefracture after plate removed, higher
infection rate in some earlier seriesinfection rate in some earlier series

38. ORIF Plate FixationORIF Plate Fixation

39. Conventional PlatingConventional Plating
Extensive exposure
Blood loss
Infection
Nonunion
Scarring

40. Submuscular PlateSubmuscular Plate
 Benefits of platingBenefits of plating
Can treat fractures at any locationCan treat fractures at any location
Any fracture patternAny fracture pattern
Any size patientAny size patient
 Avoids the risks of soft tissue exposureAvoids the risks of soft tissue exposure

41. 8.5 year old boy
Fall off a horse

43. 2 months post-op

44. External FixationExternal Fixation
 Advantages – can be applied rapidly,Advantages – can be applied rapidly,
allows soft tissue injury management ,allows soft tissue injury management ,
early mobilization, avoid castearly mobilization, avoid cast
 Disadvantages- pin site sepsis, pin siteDisadvantages- pin site sepsis, pin site
scarring, refracture, malunionscarring, refracture, malunion

45. Ex Fix Fracture at Prox PinEx Fix Fracture at Prox Pin
Keep pin diameter <20% of bone diameter.

46. Ex Fix RefractureEx Fix Refracture
6 months post injury

47. Open Femur FractureOpen Femur Fracture
PrinciplesPrinciples
 IV antibiotics, tetanusIV antibiotics, tetanus
prophylaxisprophylaxis
 emergent irrigation &emergent irrigation &
debridementdebridement
 skeletal stabilizationskeletal stabilization
 External fixation bestExternal fixation best
option with severeoption with severe
soft tissue injurysoft tissue injury
 soft tissue coveragesoft tissue coverage

48. Flexible Intramedullary NailFlexible Intramedullary Nail
AdvantagesAdvantages
 Minimal incisionMinimal incision
 Minimal blood lossMinimal blood loss
 No dissection atNo dissection at
fracture sitefracture site
 Avoids proximal bloodAvoids proximal blood
supplysupply
 Adequate stability forAdequate stability for
middle 60% fxmiddle 60% fx

49. Flexible Intramedullary NailFlexible Intramedullary Nail
DisadvantagesDisadvantages
 Rotational and lengthRotational and length
stability instability in
comminuted fracturescomminuted fractures
 Hard to controlHard to control
proximal and distalproximal and distal
fracturesfractures
 Prominence at theProminence at the
kneeknee
 RemovalRemoval

51. Most Complications – MinorMost Complications – Minor
Nail IrritationNail Irritation
don’t bend endsdon’t bend ends
- all resolved post removal- all resolved post removal

52. Outcome is better in a higher percentage ofOutcome is better in a higher percentage of
central-third fracturescentral-third fractures

53. Children with Poor Results areChildren with Poor Results are
Heavier, Cut-off Weight 108 lbsHeavier, Cut-off Weight 108 lbs

54. Complications more LikelyComplications more Likely
in Children Older than 11 Yearsin Children Older than 11 Years

55. Flexible NailsFlexible Nails
 Multiple studies fromMultiple studies from
multiple institutionsmultiple institutions
now report excellentnow report excellent
outcomes with fewoutcomes with few
complicationscomplications
 If fracture patternIf fracture pattern
allows this is theallows this is the
preferred method ofpreferred method of
fixationfixation

56. Rigid NailingRigid Nailing
 Advantages – rigid fixation, control rotationAdvantages – rigid fixation, control rotation
with interlocking screwswith interlocking screws
 Disadvantages -Risks injury to proximalDisadvantages -Risks injury to proximal
femoral epiphysis (rare but possiblefemoral epiphysis (rare but possible
devastating complication ofdevastating complication of
osteonecrosis), may interfere withosteonecrosis), may interfere with
trochanteric growthtrochanteric growth

57. Why Not Use Rigid Nail?Why Not Use Rigid Nail?
Concern about AVN /Concern about AVN /
osteonecrosis of the femoral headosteonecrosis of the femoral head
if use piriformis fossa entry portalif use piriformis fossa entry portal

58. AnatomyAnatomy
 EpiphysealEpiphyseal
blood supplyblood supply
 Traverses theTraverses the
piriformispiriformis
fossafossa
 VulnerableVulnerable
near greaternear greater
trochantertrochanter

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

60. Trochanteric Nail TechniqueTrochanteric Nail Technique
 Stay out of piriformis fossa areaStay out of piriformis fossa area
 Some use large incision/open approachSome use large incision/open approach
 Large diameter nail – ? benefit (noLarge diameter nail – ? benefit (no
reported nail fractures, nonunion rare)reported nail fractures, nonunion rare)
 Some designs now for small diameter,Some designs now for small diameter,
solid unreamed nailsolid unreamed nail

61. Small Diameter Solid Nail,Small Diameter Solid Nail,
UnreamedUnreamed

62. Trochanteric EntryTrochanteric Entry
Proximal and Distal InterlockingProximal and Distal Interlocking

63. Leave some Bone Medial to NailLeave some Bone Medial to Nail
in Trochanterin Trochanter

64. Complications of Femoral ShaftComplications of Femoral Shaft
FracturesFractures
 Limb length discrepancy – shortening as well asLimb length discrepancy – shortening as well as
overgrowthovergrowth
 Malunion (angular, rotational)Malunion (angular, rotational)
 Nonunion rareNonunion rare
 Osteonecrosis femoral head (rigid nailing)Osteonecrosis femoral head (rigid nailing)
 Refracture (ex fix, plate removal)Refracture (ex fix, plate removal)
 Osteomyelitis (after operative treatment)Osteomyelitis (after operative treatment)
 Traction pin injury to physes possibleTraction pin injury to physes possible

65. SummarySummary
 Much less frequent traction- castingMuch less frequent traction- casting
 < 5 years – early spica cast.< 5 years – early spica cast.
 5-11 years, < 100 lbs – flexible5-11 years, < 100 lbs – flexible
intramedullary nail fixationintramedullary nail fixation
 > 11, > 100 lbs – trochanteric entry nail.> 11, > 100 lbs – trochanteric entry nail.
 Very distal or very proximal fracture, orVery distal or very proximal fracture, or
severe axial instability – bridge platingsevere axial instability – bridge plating
 Severe soft tissue injury- external fixationSevere soft tissue injury- external fixation

66. Trend Toward MoreTrend Toward More
Invasive TreatmentInvasive Treatment
More high energy fracturesMore high energy fractures
Improved operativeImproved operative
techniquestechniques
Failed nonoperative treatmentFailed nonoperative treatment
Simplifies patient careSimplifies patient care
Psychological, social andPsychological, social and

67. ““Most children with fracturesMost children with fractures
of the femur have a satisfactoryof the femur have a satisfactory
outcome with any reasonableoutcome with any reasonable
form of treatment.”form of treatment.”

68. THANKSTHANKS