Fractures of the Femoral Shaft in

the Pediatric Patient

Steven Frick, MD
Original Author: Brent Norris, MD; March 2004
New Author: Steven Frick, MD; Revised August 2006
 Pediatric Femur Fractures

• 1.6 % all children's Fx’s

• 28/100,000 child years (Holland)
• 3:1 Male / Female ratio
• Children >3 y.o.- highest incidence
• Seasonal- highest summer
 Treatment Goals - Restore
• Length
• Alignment
• Rotation
 Treatment Goals - Avoid
• Osteonecrosis - disruption of blood supply
to femoral head
• Physeal injury- preserve future growth
potential (proximal and distal femoral
physes, trochanteric apophysis)
 Anatomy and Growth
• Proximal femoral physis- 30% of
longitudinal growth
• Distal femoral physis- 70% of longitudinal
growth
• Trochanteric apophysis- most of
trochanteric growth appositional after age 8
years
 Anatomy- Blood Supply
Proximal Femoral Epiphysis
• Predominantly
ascending cervical
branch (B) of medial
circumflex femoral
artery
• Physis (D) - a barrier
to intraosseous blood
supply from femoral
neck
Chung S. JBJS 58A, 1976
 Pediatric Femur Fractures-
Mechanism of Injury
• Rule out NAT in children <1year old
• Falls- young children/toddlers
• Struck by car- juvenile
• Recreational sports/activities- adolescent
• Motor vehicle crashes- all age groups
 Mechanism of Injury
• Low Energy
• High Energy

* predicts
behavior/treatment of the
fracture (Blount-1973,
Pollack-1994)
 Pediatric Femur Fractures-
Associated Injuries
• Struck by car- triad of femur fracture, torso
injuries, head injury
• Potential damage to physes of femur and
proximal tibia
• Head Injury – spasticity can make traction
and cast treatment difficult
• Abdominal injury – spica cast can constrict
abdomen and limit ability to examine
Spasticity Leading to Extreme
Angulation and Shortening
 Physical Exam
• Complete exam: head, chest, abdomen, and
other skeletal segments
• Document distal neurologic and vascular
function
• Palpate all bones
• First Aid principles - Splint or traction,
especially prior to transfer to another
institution
 Radiographic Evaluation
• AP Pelvis
• AP/Lat femur
• Visualize hip & knee joints
 Classification
• Open or closed
• Location of fracture- subtrochanteric,
diaphyseal (proximal, mid, distal third),
supracondylar
• Fracture pattern- transverse, spiral, oblique,
comminuted, greenstick
• Amount of shortening
• Angular deformity
 7 Principles
Dameron & Thompson JBJS 1959
• 1. Simplest treatment best
• 2. Initial treatment permanent when
possible
• 3. Perfect anatomic reduction not essential
for perfect function
• 4. More potential growth= more
remodeling capability
 Dameron & Thompson
JBJS 1959
• 5. Restoration of alignment more important
than fragment position
• 6. Overtreatment usually worse than
undertreatment
• 7. Immobilize/splint injured limb before
definitive treatment
 Decision Making
• Age
• Mechanism of injury
• Fracture pattern & location
• Associated Injuries
• Surgeon preference
 Traction Techniques
• Skin or skeletal
• Avoid physes if place skeletal traction pins
• Place pin perpendicular to shaft to avoid
varus/valgus angulation
• Longitudinal in line traction for comfort
prior to definitive treatment
• Split Russells traction (90-90) if awaiting
early healing prior to casting
 Immediate or Early Spica Cast-
Ideal Patient
• Less than 5 years old
• Less than 100 lbs
• Initial shortening not excessive
• Isolated injury

• Note -Spica casts used for decades and can

work for almost any pediatric femur fracture
 Spica Cast Technique
• Appropriate padding
• Cast liners may decrease skin problems
• Traction to get 0-15 mm shortening
• Mold laterally to prevent varus
• Can wedge for unacceptable angulation at 1-
2 week checkups (>10-20° varus/valgus,
>15-30° procurvatum/recurvatum – age
dependent)
 Immediate Spica Cast
• Fiberglass lighter, easier to x-ray through
• Often strong enough to obviate need for
connecting bar
• See Kasser AAOS Instructional Course
Lectures Volume XLI, 1992
 Immediate Spica Cast
• X-ray weekly for 3 weeks
• Time in spica = age in years + 3 weeks up
to maximum 8 weeks
• Wedge cast for malalignment
• Rotational alignment important at initial
cast application
 Compartment Syndrome Complicating
Early Spica Cast Treatment of
Isolated Femoral Shaft Fractures in Children
- JBJS Nov 03
 Early Sitting Spica –
3 Part, Below Knee Cast First
Method, 90-90 Position

This technique, recommended in

textbooks and articles, may increase
risk of developing compartment
syndrome, and is not recommended
 Current Technique –
Above knee cast (thigh and leg) first.
Hip and knee- 40-45 flexion, foot out.
Can include opposite thigh if desired.

Unilateral spica cast effective for low energy fractures-

see H. Epps, J Pediatr Orthop 2006
 AAOS Managing Orthopaedic
Malpractice Risk 2000
• Closed treatment of
children’s femur fractures
resulted in the most
frequent and expensive
complications, including
foot drop, skin loss,
compartment syndrome,
and malrotation /
shortening.
Mold into slight valgus
desired on initial
radiograph after casting
 Femoral Remodeling after
Fracture
• Will not correct significant rotational
malunion (Davids, Clin Orthop)
• Overgrowth 1-1.5 cm may occur, especially
in younger children treated nonoperatively
• Angular deformity will remodel significantly
in children <5 years old, less reliably in 5-10
year old, and is unlikely to be substantial in
children >10 years old
 Surgical Options
• Plate & screw fixation
• External fixation
• Flexible nailing
• Rigid nailing
 ORIF with Plates/Screws
• Advantages – rigid, technique familiar to
most surgeons, allows early motion,
favorable results reported in children with
associated head injuries
• Disadvantages- large scar, possible
refracture after plate removed, higher
infection rate in some earlier series
ORIF Plate Fixation
 External Fixation
• Advantages – can be applied rapidly, allows
soft tissue injury management , early
mobilization, avoid cast
• Disadvantages- pin site sepsis, pin site
scarring, refracture, malunion
11 yo male MVC
Pelvic fracture, ruptured bladder
External fixation
Ex Fix Fracture at Prox Pin

Keep pin diameter <20% of bone diameter.

Ex Fix Refracture

6 months post injury

 External Fixator Tips
• Appropriate size half pin diameter
• Proper pin placement relative to fracture for
biomechanical rigidity
• Do not remove ex fix until see bridging
cortices (3 or 4 of 4)
 Open Femur Fracture
Principles
• IV antibiotics, tetanus
prophylaxis
• emergent irrigation &
debridement
• skeletal stabilization
• External fixation best
option with severe soft
tissue injury
• soft tissue coverage
 Open Fractures

Can use temporary shunting to

restore distal perfusion during
debridement
 Flexible Nailing
• Advantages – allows early mobilization
without cast, cosmetic scars, avoids physes
and blood supply to femoral head
• Disadvantages – later nail removal, ends
may irritate soft tissues, may not be
amenable to some fracture patterns (very
proximal or distal, comminution)
12 yo male in ATV accident
Closed proximal third, oblique
Back at school 2 weeks
Walking at 8 weeks
 Titanium Elastic Nailing - Results
Flynn et al. JPO Jan 2001
• 57/58 excellent or satisfactory
• No rotational malunions
• 6/58 – 1-2 cm LLD
 Titanium Elastic Nailing -
Complications
Flynn et al. JPO Jan 2001
• 5/9 proximal fx - > 5 degree angulation
• 1 refracture after nail removal
• 4/58 prominent nails – 1 premature
removal
• 1 poor result – 11 yo, 15 mm short, 20
degrees varus
 Titanium Elastic Intramedullary
Nailing of Pediatric Femur Fractures:
Predictors of Complications and Poor
Outcomes
Multicenter Study

Launay, Flynn, Moroz, Frick, Kocher,

Newton, Sponseller

2004 POSNA, OTA meetings

JBJS – Br 2006
 Materials and Methods
• Surgeons at 6 pediatric
trauma centers
• Consecutive series of
femur fractures treated
with 2 retrograde
titanium nails
• Analysis of
complications
 Cohort
• 234 femoral shaft
fractures in 229
patients
• 114 complications in
87 cases
 Results
• Excellent in 148 cases
(64%)
• Satisfactory in 59
cases (26%)
• Poor in 23 cases
(10%)
 Most Complications – Minor

Nail Irritation (16%) -

don’t bend ends
- all resolved post removal
Cut Pins above Physis with
Screw Cutter
Major Complications – Reoperation or
Unresolved Perioperative Problems
23 Patients
• 17 malunions
• 9 loss of reduction
• 5 limb length discrepancy
• 2 deep infections
• 2 refractures after nail removal
• 2 protruding nails
• 1 hematoma
TEIN Yielded Excellent or Satisfactory
Results in 90% of Cases
Outcome was better in a higher percentage of
central-third fractures (p=0.55)
Children with Poor Results were
Heavier, Cut-off Weight 108 lbs
 Complications more Likely
in Children Older than 11 Years
 Recommendations :
> 11 years, > 108 lbs
– Consider other Treatment Options
Cincinnati Children’s Hospital Series
Mehlman, et al.
Presented OTA 2004
• Similar excellent results in most patients
• Poor results / complications more likely in
patients who were older and who weighed
more than 99 lbs
 Flexible Nails
• Multiple studies from
multiple institutions
now report excellent
outcomes with few
complications
• If fracture pattern
allows this is the
preferred method of
fixation for many
 Rigid Nailing
• Advantages – rigid fixation, control rotation
with interlocking screws

• Disadvantages -Risks injury to proximal

femoral epiphysis (rare but possible
devastating complication of osteonecrosis),
may interfere with trochanteric growth
Why Not Use Rigid Nail?

Concern about AVN / osteonecrosis

of the femoral head if use piriformis
fossa entry portal
 Anatomy

• Epiphyseal
blood supply
– Traverses the
piriformis fossa
– Vulnerable near
greater
trochanter

Chung S. JBJS 58A, 1976.

 Piriformis Fossa Entry Site

Thometz J, JBJS 1995.

Astion D, JBJS 1995

Raney E. JPO, 1993.
 THE DATA –
English Literature
• Estimated AVN Prevalence = 1-2%
– 1996 POSNA membership survey
– 15 cases identified
– All following Rigid Reamed Nail
– None following flexible nailing
– 1 published case after trochanteric entry

• 6 Published Case Reports

• 13 Published Case Series

 Case Series Summary
AUTHOR PUBLICATION # PTS AVG AGE IMPLANT TECHNIQUE MAL/DELAY AVN LLD>2cm PROX F/U
Kirby JPO 1981 13 14 (10) K R, PF 0 0 0 1 16
Herndon JPO 1990 16 13 + 9 (11) K, AO R, PF 0 0 0 0 16
Reeves JPO 1990 33 14 + 11 (11) K, AO R, PF 0 0 0 0 --
Ziv JOT 1984 8 8 + 4 (6) K R, PF 0 0 0 3 90
Jaglan AAOS 1992 44 12 (5) -- -- 1 -- 0 0 21
Maruenda Int Orthop 1993 29 11 +8 (7) K R, PF 0 0 0 1 80
Timmerman JOT 1993 20 13 + 10 (10) K, AO, GF R, PF 0 0 0 0 27
Beaty * JPO 1994 31 12 + 3 (10) RT R, L, PF 0 1 2 1 23
Galpin JPO 1994 22 12 + 9 (11) GK, AO R, L, PF 0 0 1 5 33
Garside POSNA 1994 17 9 + 6 (7) RT R, L, PF 0 0 0 4 27
Buford * CORR 1998 54 12 (6) ? R, L, PF 0 2 0 -- 20
Stans * JPO 1999 13 13 + 6 (11) R, L, GT 0 1 0 0 19
Townsend CORR 2000 34 12 + 1 (10) RT R, L, GT 0 0 0 0 24
TOTAL 334 12 1 4 3 15
 Thometz et al., JPO 1995
• CASE REPORT
• 12 y.o. boy,s/p MVA
• Pre-existing Asx
Acetabular Dysplasia +
Coxa Valga
• Curved Küntscher Nail
• PIRIFORMIS FOSSA
• Pain @ 9 mo. post-op
  ROH
  AVN @ 9 mo.
• Osteotomies @ 15 mo.
IM Nailing vs. Non-op Treatment
• Kirby et al., JPO 1981
– Traction / Spica vs. Closed IM Nailing

# Pts. Avg Age Hosp stay Results

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

• Herndon et al., JPO 1989

– Traction / Spica vs. Closed IM Nailing
# Pts. Avg Age Union Hosp stay Results
Spica 24 13 +3 11.5 wk 28 d Malunion (7), >2.5 cm short (3)
Nail 21 13 +9 10 wk 17 d
IM Nailing vs. Non-op Treatment

• Reeves et al., JPO 1990

– Traction / Spica vs. Internal Fixation
• 30 Kuntscher Rods
• 19 Plates
# Pts. Avg Age Hosp stay Cost Results
Spica 41 12 +4 26 d 11,800 Delayed union (4), Malunion (5),
Growth disturbance (4), Psychotic
Episodes (2)
Internal Fixation 49 14 +11 9d 8,100 Transient Peroneal Palsy (1)
 Trends in Pediatric Femur
Fracture Management
• Much less frequent traction- casting
• Immediate spica if <5 years old
• Flexible nailing for patients 5 years old to
skeletal maturity
• External fixation, plate fixation less commonly
used
• Trochanteric entry nailing for children older
than 8 years
• Submuscular plating for certain fracture
patterns
 Trochanteric Nailing
Vanderbilt Series
• >175 patients, 2 year f/u
• >age 8 years
• All healed
• No length equalization procedures or lifts
• No AVN, no coxa valga
• Nail removal at 6 -12 mos if growing or if
symptomatic in older adolescent
Not published
 Lateral Trochanteric Nailing
St. Louis Series
• 15 patients, 1 year follow-up
• Avg age 12.5 (8-17)
• All healed
• No change articulotrochanteric distance
• Avoid tip of trochanter, all placed with
lateral trochanteric entry site
 St. Louis Pediatric Femoral Nail
• 8,9 and 10 mm
• Over 8 years, >200 cases
• All patients > 8 yrs old
• >150 fractures, also osteotomies
• 135 followed > 1 year, 75 > 2 years
• No AVN
• No significant coxa vara
12 Year Old Male, 6 Mos.
 Trochanteric Nail Technique
• Stay out of piriformis fossa area
• Some use large incision/open approach
• Oveream/small nail - starting hole and canal
nonlinear
• Large diameter nail – ? benefit (no reported
nail fractures, nonunion rare)
• Some designs now for small diameter, solid
unreamed nail
Small Diameter Solid Nail,
Unreamed
 Trochanteric Entry
Proximal and Distal Interlocking
Leave some Bone Medial to Nail
in Trochanter
 Trends in Pediatric Femur
Fracture Management
• Trochanteric entry rigid
nailing- new designs, large
experience in some centers
• Limited/minimal incision
plating techniques- bridge
plate concept- popular in few
trauma centers, useful for
some fracture
patterns/locations
• External fixation for severe
soft tissue injuries in open
fractures
Percutaneous Bridge
Plating

Courtesy of E.M. Kanlic, MD, PhD

 Bridge Plating
• Limited incisions and
dissection
• Usually 4.5 mm plate and
screws
• Long plate, few screws, do
not open fracture site
• An “internal” fixator
• Excellent results published by
Kanlic (Clinical Orthop) and
Sink (J Pediatr Orthop)
 Submuscular Plating
• Small incisions either end
• Extraperiosteal, slide plate
• At least 2 screws in each main fragment
• Clustered screws vs. near-near, far-far
• Reduce fracture and maintain before plating
(bumps or temporary ex-fix)
 Metal Removal
• Some controversy
• Commonly recommended
• Survey studies – remove
IM devices in children
• Some centers now do not
electively remove
asymptomatic implants
• Excellent review by
Peterson, J Pediatr Orthop
2005
 Complications of Femoral Shaft
Fractures
• Limb length discrepancy – shortening most
frequent
• Malunion (angular, rotational)
• Nonunion rare
• Osteonecrosis femoral head (rigid nailing)
• Refracture (ex fix, plate removal)
• Osteomyelitis (after operative treatment)
• Traction pin injury to physes possible
12 yo 200 lb female – unstable fx
treated with flexible nails – healed
with 30 degree procurvatum malunion
13 yo male hit by car
Lengthened over Healed with equal LL
Initially 2 retrograde nail
TEN
1 became prominent
Courtesy of
Healed 5 cm short
S.H.Sims, MD
 Trend Toward More
Invasive Treatment
• More high energy fractures
• Improved operative techniques
• Failed nonoperative treatment
• Simplifies patient care
• Psychological, social and financial
reasons
 Timmermann and Rab
JOT 1993

• “Most children with fractures of

the femur have a satisfactory
outcome with any reasonable form
of treatment.”
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