Management of Femur in Pediatric Group Age

1. Management of Femur in
Pediatric Group Age
Fairuz Khamzah

2. Introduction
• Femur fracture in pediatric patient is not the
same in adolescence patient in view of bone
maturity
• High suspicion for child abuse required
• Femur fractures are the 2nd most common child
abuse associated fracture after humerus
fractures

3. Acceptable Criteria
• Accept if:
▫ <1.5 cm shortening
▫ <500 varus
▫ <15o valgus
▫ <200 anterior or posterior bowing

4. Choice Of Treatment
• Non Operative
• External Fixator
• Flexible Intermedullary nail
• Rigid Intramedullary Nail
• Plating

5. Decision Making

6. Non Operative
• Pavlik Harness
• Immediate Spica Cast
• Traction then Spica Cast

7. Pavlik Harness
• indications
▫ children up to 6 mos.
• technique
▫ avoids the need for sedation or anesthesia
▫ straps can be adjusted to manipulate fracture
• complications
▫ can compress femoral nerve if excessive hip
flexion is used in presence of a swollen thigh
 identified by decreased quadricep function

8. Hip Spica

9. Immediate Hip Spica
• indications
▫ children 7 m - 5 years with < 2 - 3 cm of shortening
▫ relatively contraindicated with polytrauma, open fractures and shortening > 2-3
cm
• technique
▫ applied with reduction under sedation or with general anesthesia
▫ hips are flexed 60-90° and are placed in approximately 30° of abduction
▫ knees are placed in 90° of flexion
▫ external rotation is typically needed to correct rotational deformity
• follow-up
▫ weekly radiographs to monitor for loss of reduction for first 2 to 3 weeks
 cast wedging can be used to correct deformities
▫ healing times vary from 4 - 8 weeks based on age
• complications
▫ compartment syndrome
 decreased with applying smooth contours around popliteal fossa, limiting knee
flexion to < 90° and avoiding excessive traction
 monitored for by observing the child's neurovascular exam and level of comfort

10. Skeletal/Skin Traction

11. • indications
▫ children 7 mos. - 5 yrs. of age with > 2 - 3 cm of
shortening
• technique
▫ placed in distal femur proximal to distal femoral
physis
 proximal tibial traction can cause recurvatum due to
damage to the tibial tubercle apophysis
▫ used for 2-3 weeks to allow early callus formation
▫ spica casting then applied until fracture healing

12. Early Hip Spica VS Delayed Hip Spica
• Skin traction followed by Spica Cast and early
spica cast for femur shaft fracture in children (3-
10 years) is comparable.
• M.Aslam et all, Skin Traction followeed by spica cast versus early spica cast in femoral shaft fracture in
children, Pakistan Journal of surgery,2008

13. External Fixator
• indications
▫ damage control orthopaedics in a polytrauma patient
▫ open fractures
▫ associated vascular injuries requiring revascularization
▫ fractures with associated soft tissue concerns
▫ segmental or significantly comminuted fractures
▫ multiply injured patient
• technique
▫ applied laterally
 avoid disruption and scarring of quadriceps
▫ 10 - 16 weeks of fixation is typically needed for solid
union to occur
• complications
▫ pin tract infections are frequent
 as high as 50% of fixator related complications
 treated with oral antibiotics and pin site care
▫ higher rates of delayed union, nonunion and malunion
▫ increased risk of refracture after removal of fixator
 1.5 - 21%

14. • Miner et al found five cases of LLD, 24 pin tract
infections and eight refractures in 37 patients
studied in similar age groups (4-14),high rates of
infection and refracture (ranging from 1 to 22%)
after pin removal have restricted the indications
of external fixator to some grades of open
fractures and for damage control in a
polytraumatized patient.

16. Submuscular bridge plate fixation
• indications
▫ comminuted, length unstable fractures
▫ very proximal or very distal fractures
• technique
▫ fracture is provisional reduced with closed or percutaneous techniques
▫ small incisions are made proximally and distally and a plate is placed between the
periosteum and vastus lateralis on the lateral side of the femur
▫ a 12 to 16 hole 4.5mm narrow LC-DC plate with 3 screws proximal and 3 screws
distal to the fracture will typically suffice
▫ weightbearing is restricted until visible callus formation at an average of 5 weeks
• advantages
▫ stability allows for early mobility
▫ preserves blood supply to femoral head
▫ performed with minimal surgical exposure and soft-tissue dissection
• disadvantages
▫ steep learning curve
▫ load bearing implant
▫ multiple stress risers following removal of hardware

18. Antegrade Rigid Intramedullary Nailing
• Offers maximum stability and load sharing
• Indication:
▫ > 11 years
▫ BW> 45kg
• Technique:
▫ GT entry or lateral entry nail
▫ Do not cross distal physis
• Complication:
▫ ON risk is 1-2% with piriformis entry

20. Flexible Intramedullary Nailing
• indications
▫ treatment of choice for most simple, length stable fracture patterns in children 6 -
10 years
▫ adolescent patient weighing less than 45kgwith a length stable fracture
• technique
▫ allows load sharing and quick moblization of the patient
▫ nail size determined by multiplying width of narrowest portion of femoral canal
by 0.4
 the goal is 80% canal fill
▫ two nails of equal size are inserted retrograde beginning approximately 2 -2.5 cm
above the distal femoral physis
• complications
▫ most common complication is pain at insertion site near the knee
 reported in up to 40% of patients
▫ increased rate of complications in patients >11 - 12 years of age or > 45 kg
▫ increased rates of malunion and shortening in very proximal and distal fractures,
as well as significantly comminuted fractures

23. Refferences
• John M. Flynn, MD, and Richard M. Schwend,
MD ; Management of Pediatric Femoral Shaft
Fractures, J Am Acad Orthop Surg 2004;12:347-
359
• Orthobullets Website