Femoral Shaft Fractures in
Children
Original: M.L. Routt, Jr., M.D.
Revised October, 2011: Andrew R. Evans, M.D.
Pediatric Femoral Shaft
Fractures
One of the most common pediatric lower
extremity fractures
Most common pediatric fracture requiring
hospital admission.
Treatment Options
Traction
Spica Casting
Pins & Plaster
External Fixation
Internal Fixation
– Plate/Screws
– Flexible nails
– Rigid Intramedullary rods - trochanteric vs. lateral entry
Pediatric Femoral Shaft
Fractures
Treatment is often directed by the
patient’s age
– 0-6 months
– 6 months - 5 years
– 5 - 11 years
– 11 years - skeletal maturity
Other considerations
– Additional injuries, social
situation, physician preference,
etc.
Femoral Shaft Fractures:
0 - 6 Months
40% of femoral diaphyseal fractures in patients <1 year of age are non-accidental
Child Abuse - approximately 15% of femoral shaft fractures in patients <36 months
of age result from abuse
>90% of pediatric femoral shaft fractures resulting from abuse occur in children <36
months of age
Femoral Shaft Fractures:
0 - 6 Months
AAOS Clinical Practice Guideline: All children < 36 months of age with a
diaphyseal femur fracture must be evaluated for child abuse
– Complete History & Physical examination
– Consultation with Pediatrician, Family Practitioner, and/or Child Abuse
Team
– Skeletal survey if warranted
•
Femoral Shaft Fractures:
0 - 6 Months
Pavlik harness
•
•
Spica casting
•
•
•
Stable union typically
achieved within 5 weeks
Higher risk of skin
complications than Pavlik
Waterproof cast liners
improve sanitation
Spica casting with
incorporated distal femoral
traction pin
•
May decrease incidence of
unacceptable shortening
and frontal plane
malalignment
•
Femoral Shaft Fractures:
6 months - 5 years
Diaphyseal Femur Fractures:
•
<2cm shortening
•
Early spica casting (90°/90°)
•
•
•
•
•
Enhanced ease of care
Shorter hospital stay
No defined optimal weight range
Spica casting in ED versus OR
yield similar reduction quality and
complication rates
Traction with delayed spica casting
•
Skin traction typically ineffective;
skeletal traction often required
Femoral Shaft Fractures:
6 months - 5 years
•
Diaphyseal Femur Fractures:
•
> 2cm shortening
•
Spica casting
•
•
•
Mode of treatment may be
altered if deemed
necessary
External fixation
•
•
Insufficient evidence to
recommend for/against
(AAOS Clinical
PracticeGuideline)
Lower incidence of
malunion compared to
spica casting
Flexible IM nailing may be
considered for the oldest, most
Femoral Shaft Fractures:
6 months - 5 years
Insufficient evidence exists to recommend any specific degree of angulation,
rotation, or shortening that is unacceptable (AAOS Clinical Practice
Guideline)
– Traditionally:
• Varus/valgus deformity more poorly tolerated than flexion/extention
deformity
• Up to 30° of rotational malunion can be tolerated
• Remodelling occurs to a greater extent in younger children with more
growth potential
• Overgrowth is a biologic response to fracture in this age group but is
unpredictable
Femoral Shaft Fractures:
5 - 11 years
Skeletal Traction
– Typically used to precede definitive treatment
particularly in severely traumatized patients
Spica casting
– Poorly tolerated,
– Higher risk of malunion
Femoral Shaft Fractures:
5 - 11 years
External Fixation
– Lower incidence of malunion than spica casting
– Ease of hardware removal compared to plates or nails
– Risk of re-fracture, pin site infection,
scarring/stiffness of IT band
– Excellent mode of provisional fixation
Femoral Shaft Fractures:
5 - 11 years
Flexible (Elastic) Intramedullary Nails
– Preferred method for treatment of most femoral
disphyseal fractures in this age group
– Titanium or stainless steel (Enders)
– Antegrade or retrograde (more common) insertion
– Outcomes best when used to treat stable fracture patterns
– Shorter hospital stay
– Fewer adverse events
– More rapid return to school
– Most common complication is irritation at distal
insertion sites
– Increased risk of poor outcome in children weighing
>108 lbs (49kg)
Femoral Shaft Fractures:
5 - 11 years
Sub-muscular plating
– Compression versus bridging plate
techniques
• Open reduction versus minimally
invasive plate osteosynthesis
(MIPO)
• May address stable or unstable
fracture patterns effectively
– Indications for plate removal remain
controversial
Femoral Shaft Fractures:
11 years - Skeletal Maturity
External Fixation
– Useful to achieve provisional fixation of femoral
fractures in severely injured patients or open fractures
– May be used for definitive treatment of subtrochanteric
or distal metadiaphyseal fractures that are less amenable
to plate or nail fixation
– Avoids direct fracture exposure, minimizes blood loss,
minimizes risk of physeal injury
– More frequent complications include delayed union and
refracture after device removal
Femoral Shaft Fractures:
11 years - Skeletal Maturity
Flexible intramedullary nails
– Outcomes optimized when use is
limited to stable fracture patterns
– Higher risk of complications in patients
>11 years of age, >108 lbs (49kg), and
unstable fracture patterns
– Commonly reported complications:
knee pain at insertion site, nail
prominence, nail migration, fracture
shortening/malunion, delayed union
Femoral Shaft Fractures:
11 years - Skeletal Maturity
Sub-muscular plating
– Compression versus bridging plate techniques
• Open reduction versus minimally invasive plate
osteosynthesis (MIPO)
• May address stable or unstable fracture patterns
effectively
• Accurate and stable reductions are achievable;
malunions uncommon
Femoral Shaft Fractures:
11 years - Skeletal Maturity
– Submuscular plating:
• Open reduction with soft-tissue
stripping fracture exposure may
increase risk of non-union
• Risk of re-fracture if plate is removed
Femoral Shaft Fractures:
11 years - Skeletal Maturity
Rigid intramedullary nailing - greater trochanteric entry femoral
nail
– Well suited for unstable fracture patterns
– Patients >108lbs (49kg) who are not candidates for
flexible IM nailing
– Piriformis or near-piriformis entry nailing is NOT a
treatment option
• Risk of injury to the lateral ascending cervical
branches of the medial femoral circumflex vessel in
the piriformis fossa
• Increased risk of femoral head osteonecrosis (≥4%)
– Risk of coxa vara due to trochanteric apophyseal growth
arrest
– Permits rapid mobilization
Femoral Shaft Fractures:
11 years - Skeletal Maturity
Femoral head osteonecrosis
Femoral Shaft Fractures:
11 years - Skeletal Maturity
Rigid intramedullary nailing- lateral entry femoral nail
– Similar indications to trochanteric entry nails
– Designed to avoid injury to circumflex vessels
and trochanteric apophysis
Pediatric Femoral Shaft
Fractures
Unable to recommend for/against removal of surgical implants from asymptomatic
patients with healed diaphyseal femur fractures (AAOS Clinical Practice
Guideline)
– Risks include refracture, hematoma, infection, scarring, etc.
Regional anesthesia is an option for perioperative care (Hematoma and/or Femoral
Nerve Block) - AAOS Clinical Practice Guideline
– Reduced narcotic administrated demonstrated with hematoma block
References
Aksahin E, et. al. Immediate Incorporated Hip Spica Casting in Pediatric Femoral Fractures: Comparison of Efficacy Between Normal and High Risk
Groups. Journal of Pediatric Orthopaedics 2009; 29(1): 39-43.
Anglen JO, Choi L. Treatment Options in Pediatric Femoral Shaft Fractures. Journal of Orthopaedic Trauma 2005; 19(10): 724-733.
Flynn HM, Luedtke LM, Ganley TJ, Dawson J, Davidson RS, Dormans JP, Ecker ML, Gregg JR, Horn BD, Drummond DS. Comparison of Titanium Elastic
Nails With Traction and a Spica Cast to Treat Femoral Fractures in Children. J Bone & Joint Surg Am 2004; 86: 770-777.
Flynn JM, Schwend RM. Management of Pediatric Femoral Fractures. JAAOS 2004; 12(5): 347-359.
Garner MR, Bhat SB, Khujanazarov I, Flynn JM, Spiegel D. Fixation of Length-Stable Femoral Shaft Fractures in Heavier Children. Journal of Pediatric
Orthopaedics 2011; 31(1): 11-16.
Gautier E, Ganz K, Krugel N, Gill T, Ganz R. Anatomy of the Medial Femoral Circumflex Artery and Its Surgical Implications. J Bone & Joint Surg Br
2000; 82(5): 679-683.
Hosalkar HS, Pandya NK, Cho RH, Glaser DA, Moor MA, Herman MJ. Intramedullary Nailing of Pediatric Femoral Shaft Fractures. JAAOS 2011; 19(8):
472-481.
Mansour AA, Wilmoth JC, Mansour AS, Lovejoy SA, Mencio GA, Martus JE. Immediate Spica Casting of Pediatric Femoral Fractures in the Operating
Room Versus the Emergency Department: Comparison of Reduction, Complications, and Hospital Charges. Journal of Pediatric Orthopaedics 2010;
30(8): 813-817.
Kocher MS, Sink EL, Blasier RD, Luhmann SJ, Mehlman CT, Scher DM, Matheney T, Sanders JO, Watters WC, Goldberg MJ, Keith MW, Haralson RH,
Turkelson CM, Wies JL, Sluka P, Hitchcock K. AAOS Clinical Practice Guideline Summary: Treatment of Pediatric Diaphyseal Femur Fractures.
JAAOS 2009; 17: 718-725.
Poolman RW, Kocher MS, Bhandari M. Pediatric Femoral Fractures: A Systematic Review of 2422 Cases. Journal of Orthopaedic Trauma 2006; 20(9):
648-654.
Sagan ML, Datta JC, Olney BW, Lansford TJ, McIff TE. Residual Deformity After Treatment of Pediatric Femur Fractures With Flexible Titanium Nails.
Journal of Pediatric Orthopaedics 2010; 30(7): 638-643.
References
Sink EL, Faro F, Polousky J, Flynn K, Gralla J. Decreased Complications of Pediatric Femur Fractures With a
Change in Management. Journal of Pediatric Orthopaedics 2010; 30(7): 633-637.
Wright JG. The Treatment of Femoral Shaft Fractures in Children: A Systematic Overview and Critical
Appraisal of the Literature. Canadian Journal of Surgery 2000; 43(3): 180-189.
If you would like to volunteer as an author for the Resident
Slide Project or recommend updates to any of the following
slides, please send an e-mail to ota@aaos.org
E-mail OTA
about
Questions/Comments
Return to
Pediatrics
Index