Post on 02-Jun-2017
Femoral Shaft Fractures in Children
Description
• Femoral shaft fractures are defined as those >5 cm below the lesser trochanter, but above the distal metaphyseal (wider) portion of the lower femur.
• The location usually is specified as:– Proximal– Midshaft– Distal
Epidemiology
• Fractures of the femur are more common:– In areas of high population density or low
socioeconomic level– In children 0-3 and 12-16 years old– Represent 1.6% of all fractures in the pediatric
population.– Boys are more commonly affected at a ratio of 6:1.
MECHANISM OF INJURY
• Direct trauma: Motor vehicle accident, pedestrian injury, fall, and child abuse are causes.
• Indirect trauma: Rotational injury.• Pathologic fractures: Causes include
osteogenesis imperfecta, nonossifying fibroma, bone cysts, and tumors.
Femoral Shaft Fractures
Femoral Shaft FractureClassification
• Descriptive• Open versus closed• Level of fracture: proximal, middle, distal
third• Fracture pattern: transverse, spiral, oblique,
butterfly fragment• Comminution• Displacement• Angulation
Femoral Shaft FracturesClinical Features
• Obvious deformity• 50% have ligamentous instability of the knee• Neurovascular injuries rare in closed fractures• Fracture of Proximal 2/3
– Proximal fragment abducted, flexed, and externally rotated due to pull of gluteal and iliopsoas muscles of trochanters
• Fracture of Distal 1/3– Hyperextension of distal fragment due to pull of
gastrocnemius
Treatment Options
• Traction• Spica Casting• Pins & Plaster• External Fixation• Internal Fixation
– Plate/Screws– Flexible nails– Rigid Intramedullary rods - trochanteric vs.
lateral entry
Operative Indications
• Multiple trauma, including head trauma• Open fracture• Vascular injury• Pathologic fracture• Uncooperative patient• Body habitus not amenable to spica casting
Femoral Shaft Fractures: 0 - 6 Months
• Pavlik harness or a posterior splint is indicated.
• Traction and spica casting are rarely needed in this age group.
Femoral Shaft Fractures: 6 months - 5 years
• Immediate spica casting is nearly always the treatment of choice (>95%).
• Skeletal traction followed by spica casting may be needed if one is unable to maintain length and acceptable alignment; a traction pin is preferably placed proximal to the distal femoral physis.
• External fixation may be considered for multiple injuries or open fracture
Femoral Shaft Fractures: 6 months - 12 years
• Flexible intramedullary nails placed in a retrograde fashion are frequently used in this age group.
• External fixation or bridge plating may be considered for multiple injuries or open fracture.
• Some centers are using interlocked nails inserted through the greater trochanter (controversial).
• Spica casting may be used for the axially stable fractures in this age group.
Femoral Shaft Fractures: > 2 years
• Intramedullary fixation with either flexible or interlocked nails is the treatment of choice.
• Locked submuscular plates may be considered for supracondylar or subtrochanteric fractures.
• External fixation may be considered for multiple injuries or open fracture
Complication
Early :• Infection• Vascular injury• Compartment syndrome
Late :• Delayed union• Malunion • Nonunion