Pediatric Femur Fracture
synonyms:
Pediatric Femur Fx ICD-9
- 821.01(closed)
- 821.11(open)
Pediatric Femur Fx Etiology / Epidemiology / Natural History
Pediatric Femur Fx Anatomy
Pediatric Femur Fx Clinical Evaluation
- ATLS resuscitation. These can be high enegery injuries, assessment should begin with the A,B,C's.
- Obvious deformity of thigh often with limb shortening
- Document neurovascular exam before and after any treatment.
- Evaluate for hemarthrosis: indicates associated meniscal tear or knee ligamentous injury.
Pediatric Femur Fx Xray / Diagnositc Tests
- A/P and lateral views of femur. High quality A/P and lateral views of the hip and knee are indicated to r/o associated injuries, especially femoral neck fractures.
- CT: consider fine cut CT through the femoral neck if concern for associated femoral neck fracture (Tornetta P, JBJS 2007;89A:39).
Pediatric Femur Fx Classification / Treatment
- Spiral, transverse, oblique, greenstick, comminuted. Proximal midshaft, distal, pathologic
- Treatment options:pavlic harness, spica cast, Ex Fx, Flexible IM nail, Rigid IM nail, ORIF, traction
- Acceptable alignment at union for 2-10yr olds: <15 varus or valgus, <20 anterior or posterior, ,<30 malrotation, <2.0cm shortening.
- Infants(1-6 months) = pavlic harness +/- supplemental splint. Fractures of the femur in newborns heal very rapidly. Infants adapt rapidly to the harness, and can be carried and held by the parents, facilitating mother-child bonding (Stannard JP, JPO 1995;15:461-466) (Podesszwa DA, JPO 2004;24:460). Evaluate for child abuse.
- 6months - 5years with less than 2cm of shortening =early spica casting; f.u xray at 7-10 days; cast removed when early callus is present, usually 6-8 wks. (Epps HR JPO 2006;26:491). Children <36months old with femur fractures should be evaluated for child abuse.
- 6months - 5years with greater than 2cm of shortening =AAOS guideline reports treatment recommendation is inconcluslive. Consider early spica casting vs flexible nails (older children). Children <36months old with femur fractures should be evaluated for child abuse.
- 7-11yrs=flexible intramedullary nails. Consider external fixation, ORIF
- 11-16yrs = trasntrochateric nail, consider external fixation, ORIF. Piriformis entry nails should not be used.
- Flexible nails-supine on radiolucent table, medial and lateral incisions for entry point into bone just proximal to physis. Pre-bend nails to allow passage. Nail options include Synthes flexible nails(titanium, cut to size after insertion) and Enders(stainless steel, have eye for easy removal, cheaper, must measure length before insertion) nails. Both come in sizes from 2.5-4.5mm with multiple lengths. Goal=80% canal fit. (HO CA, JPO 2006;26:497).
- External Fixation=unilateral lateral ex fix, generally four pins. Transverse fractures treated with an external fixator heal with poor callus and have a high refracture rate. May also refractrue through pin sites. Consider frame dynamize before removal (GreenWB:CORR 1998; 5:86). (Gregory P, JOT 1996;10:191), Blasier RD, JPO 1997;17:342).
- Traction=. Femoral pin traction is safe and effective but requires prolonged bed rest and results in considerable muscle wasting and a slow return to function.
- Rigid IM nailing can be done through greater trochanter. Piriformis fossa starting point risks AVN. )(Kanellopoulos AD, J Trauma 2006;60:217).
- ORIF= effective, by requires considerable tissue dissection with large scar formation. It also requires a rather extensive dissection for later plate removal )Caird MS, JPO 2003;23:448). (Hedequist DJ, JOT, 2005;19:276).
- Traction-prolonged bed rest(3-4wks), muscle wasting, slow return to function
Pediatric Femur Fx Associated Injuries / Differential Diagnosis
- ChildAbuse: especially before walking age. buckle fracture is consistent with child falling on their own leg; spral fracture = child landing while in motion; transverse fracture = older, heavier person falling onto child.
Pediatric Femur Fx Complications
- Leg Length Discrepancy: overgrowth common in ages 2-10y/o.
- Infection
- Delayed union
- Nonunion
- Vascular injury
- Compartment syndrome
- tibial physeal closure and development of genu recurvatum deformity (Bowler, J Pediatric Orthop 10:653;1990)
- Painful hardware (pain at flexible nail insertion site)
Pediatric Femur Fx Follow-up Care
- Time to union is 8-10 weeks.
- Consider Hardware removal after fracture union. Generally at 6-12 months. Need for hardware in asymptomatic patients in inconclusive.
Pediatric Femur Fx Review References
- AAOS Pediatric Femur Fracture Guidelines.
- Ligier JN, Metaizeau JP, Prevot J, Lascombes P: Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-77.
- Heinrich SD, Drvaric D, Darr K, MacEwen GD: Stabilization of pediatric diaphyseal femoral fractures with flexible intramedullary nails (a technique paper). J Orthop Trauma 1992;6:452-459.
- Flynn JM, JBJS 2004;86:770
- Canale ST, ICL 1995;44:255
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