Femoral Fractures

Aetiology

Paediatric femoral fracture

 

Varies per age group

 

Trauma

- 60%

 

Non Accidental Injury

- 15 - 30%

- suspect if non walker / < 1 year

- walking status single best indicator of risk

- paediatric team to investigate

- history taking from parent

- consider metabolic investigations

 

Osteogenesis Imperfecta / Pathological fracture through cysts

- 10 %

 

Epidemiology

 

Bimodal distribution

- peaks at 2-3 and 16-19 years

- younger group from falls

- older group from traffic accidents

 

Management

 

Immediate management

 

Gallows traction

 

Child 0 - 2 years and < 12 kg

 

Gallows tractionGallows traction


Hamilton- Russell (90/90) traction

- skin traction on lower leg

- place padded sling behind knee to slightly flex

https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/femoral-shaft/simple-transverse-distal-1-3-fractures/nonoperative-treatment-with-limited-resources#general-considerations

 

Algorithm

 

0 - 6 months

- Pavlik harness (neonates with fracture occuring during birth)

- spica

 

6 months - 4 years

- spica

 

5 years - 11 years

- length stable - flexible nails

- length unstable - plate (bridge or open)

 

> 12 years

- length stable - lateral entry nail or TENS (<50kg)

- length unstable - plate

 

15+

- IMN (lateral or piriformis entry)

 

Polytrauma/ Soft tissue (any age)

Consider external fixator

 

Management 0 - 6 months

 

Aetiology

- difficult delivery

- Osteogenesis imperfecta

- Non accidental injury

 

Management

 

A. Pavlik harness

 

B. Spica

 

Podeszwa et al. J Pediatr Orthop

- < 1 year child

- 24 in Pavlik compared with 16 in spica

- spica patients tended to be older and heavier

- no difference in outcomes

- 1/3 spica patients had a skin problem

https://www.ncbi.nlm.nih.gov/pubmed/15308892

 

Management 6 months - 4 years

 

Goals

- < 15o angulation in all planes

- < 2 cm shortening

 

Options

 

1. Double leg spica

2. Single leg spica

 

Leu et al. JBJS Am 2012

- RCT of 52 pediatric femoral shaft fractures

- single v double leg

- all healed satisfactorily

- single leg more likely to fit into car seats / chairs

https://pubmed.ncbi.nlm.nih.gov/22695973/

 

Flynn et al. JBJS Am 2011

- walking hip spica v traditional hip spica

- walking spica patients more likely to need wedge correction of mal-alignment

https://pubmed.ncbi.nlm.nih.gov/22159855/

 

Paediatric Femur Fracture

 

Technique Hip spica

 

Contra-indication

- abdo injury

- head injury (high spasticity)

 

Hip Spica TableHip Spica 1

 

Hip spica 2Hip spica 3

 

Technique

- under GA, on spica table (posterior thorax on post)

- apply stocking net over body and legs

- pressure pads over ASIS

- wool applied

- must have roll of wool over abdomen to give space to breath

- 90/90 sitting spica (knees 90o, hip 90o), hips 30o abduction, 15o ER

 

Check position under fluoroscopy

- accept <2 cm shortening

- 15o varus / valgus

- 20o flexion / extension

- 10o rotation

 

Options

- one and one half leg: to knee on contralateral side, include ankle on ipsilateral side

- single-leg spica cast: to ankle on ipsilateral side, no inclusion of contralateral thigh

 

Post spiceacare

- weekly x-ray for 2 - 4 weeks to detect malalignment

- usually for 6 - 8 weeks depending on age

 

Postoperative care instructions from Queensland Health

https://www.childrens.health.qld.gov.au/fact-sheet-caring-for-your-child-in-a-hip-spica/

 

Remodelling

 

Paediatric Femur Fracture Hip SpicaPaediatric Femur Fracture 1 monthPaediatric Femur Fracture 2 monthPaediatric Femur Fracture 6 monthsPaediatric Femur Fracture 1 year

 

Management 5 - 11 years

 

Immediate Management

 

Thomas Splint / Balanced Traction

 

Femoral Fracture Thomas Splint

 

Technique

- analgesia +/- sedation

- Thomas splint with 2 fingerbreadths diameter clearance around thigh

- cushioning for leg to sit in Thomas splint

- traction bed

- application skin traction to leg, tied to end of Thomas splint, traction by twisting paddlepop stick

- weight off end of Thomas over pulley at end of bed

- this pulls splint away from ischium and peroneum

- rope taken over 2 pulleys at top of bed with weight suspended to elevate Thomas splint from bed

- weight is tied to bed at top to prevent falling onto leg

- splint must be checked 2 x day to prevent pressure areas, needs regular oiling

 

Definitive management

 

1. Hip spica

2. Titanium elastic nails (length stable)

3. Plate (length unstable)

 

Hip spica v TENS

 

Iman et al Arch Bone Jt Surg 2018

- systematic review of 12 studies and 1012 patients

- patients 2 to 16 years

- hip spica v TENS

- reduced malalignment and faster independent walking with TENS

https://pubmed.ncbi.nlm.nih.gov/29911134/

 

TENS v Plate

 

Luo et al. Orthop Surg 2019

- plate v TENS in 51 patients

- average union 2.2 months (range, 1 - 6 months)

- no LLD, rotational or angular deformity in any patient

https://pubmed.ncbi.nlm.nih.gov/31456324/

 

Flexible nails / Titantium Elastic Nails

 

Indications

- length stable i.e simple transverse, short oblique, midshaft

- maximum weight up to 50 kg / 12 years old

 

Contra-indications

- unstable fracture patterns

- > 50 kg

 

Pediatric Femoral Fracture SpiralPediatric Femoral Fracture Comminuted

 

Technique

 

Synthes surgical technique PDF

http://synthes.vo.llnwd.net/o16/LLNWMB8/INT%20Mobile/Synthes%20International/Product%20Support%20Material/legacy_Synthes_PDF/DSEM-TRM-0115-0290-3_LR.pdf

 

Wires

- 30 - 40% of diameter of diaphyseal medullary canal

- i.e. if canal 10 mm wide, use 2 x 4 mm

- 6 - 8 years (3 mm)

- 9 - 11 years (3.5 mm)

- 12 - 14 years (4 mm)

- recommend using 2 wires same diameter to avoid rotational instability

- 3 point bend in wires to get 3 point fixation

- aim for bend at fracture site

 

Entry points

- medial and lateral insertion

- 1 - 2 cm proximal to distal femoral physis

- oblique entry with awl in direction of nail insertion

- can open with drill bit

- beware proximity of the femoral artery medially

- entry points should be symmetrical

 

Wire passage

- bend wire for 3 point fixation

- also bend the tip of the wire

- can use F Tool to reduce fracture

- may need small incision and open reduction

- medial entry wire will pass into femoral neck

- lateral entry wire will pass into greater trochanter

- use designated TEN wire cutter to cut wires

- cut off, tap in slightly further, leave 1.5 cm out so can retrieve

- wires that are too prominent can cause bursa / limit flexion / pain / protrude through skin

 

Vumedi video

https://www.vumedi.com/video/elastic-stable-intramedullary-nailing-for-femoral-shaft-fracture/

 

Acceptable alignment

- 10o varus / valgus

- 15o flexion / extension

- 15 mm shortening

 

Post op

- early mobilisation with crutches

- touch weight bearing

- begin full weight bearing with union (typically 6 - 8 weeks)

- remove TENS at 6 months

 

Complications

 

Narayanan et a. J Paediatr Orthop 2004

- reported on 79 patients treated with flexible nails

- pain and irritation at insertion site common

- malunion / loss of reduction assocatiated with nails of differing diameters and increased comminution

https://pubmed.ncbi.nlm.nih.gov/15205616/

 

Titanium v stainless steel flexible nails

 

Mohamed et al. Europ J Orthop Surg Traumatol 2017

- systematic review of 5 papers

- mixed results

- no obvious difference in malunion or union rates

https://pubmed.ncbi.nlm.nih.gov/24077687/

 

Plate

 

Indication

- length unstable fractures (spiral / comminuted)

- very distal or proximal fractures

- patient inability to non weight bear (cognitive impairment / developmental delay)

 

Options

 

1. Open Plating

 

Paediatric Femoral Fracture Plate

 

2. Submuscular bridge plating

 

Bridge plating paediatric femur fracture

 

Technique

- supine on radiolucent table or traction table

- incision 5cm proximal or distal (depending # site)

- blunt dissection to periosteal layer

- run bristow or cobb elevator submuscularly

- 3.5 or 4.5mm LCP plate (depending on patient size and age)

- place plate submuscularly

- use stab incisions to place 3 screws above /below fracture

- sufficient spread

 

Postop

- TWB / PWB for 6/52 until union

- removal at 6/12

 

Results

 

Abott et al. J Paediatr Orthop 2013

- comparison of open v submuscular bridge plating in 79 patients

- increased blood loss in open plating

- increased rotational asymmetry in bridge plating

- no other difference between two groups

https://pubmed.ncbi.nlm.nih.gov/23752149/

 

External Fixation

 

Indication

open wounds as temporary stabiliser

 

Complications

- pin site infection

- malunion

- refracture post removal

https://www.ncbi.nlm.nih.gov/pubmed/10823615

 

Management 12 years and over

 

Issues

 

1. Less potential to remodel (especially > 10)

2. Usually too heavy for flexible nails

3. Risk of AVN with standard nails

 

AVN

 

MacNeil et al. J Paediatr Orthop 2011

- systematic review of risk of AVN after used of rigid locking nails

- piriformis fossa AVN rate 2%

- tip greater trochanter AVN rate 1.4%

- lateral entry / trans-trochanter AVN rate 0%

 

Acceptable alignment

 

Varus / valgus 5o

Flexion / extension 10o

Shortening 1 cm

 

Options

 

1. Flexible nails

- < 50 kg

 

2. Plate

 

Advantage

- very safe option

- avoid growth plates

 

Disadvantage

- incidence of refracture with plate removal

 

3.  Antegrade Lateral Entry Trans-trochanteric Femoral Nail

 

Keeler et al. J Paediatr Orthop 2009

- 80 femoral fractures treated with lateral entry femoral nails

- no AVN

- no malunion or nonunion

https://pubmed.ncbi.nlm.nih.gov/19461375/

 

Synthes surgical technique PDF

http://synthes.vo.llnwd.net/o16/LLNWMB8/INT%20Mobile/Synthes%20International/Product%20Support%20Material/legacy_Synthes_PDF/DSEM-TRM-0815-0470-1_LR.pdf

 

4.  External Fixation

 

Management > 15 years old

 

Standard antegrade nail 

- safe

- no risk of AVN

 

Subtrochanteric fractures

 

Issues

 

Non operative treatment rarely indicated in older children as acceptable alignment hard to maintain

- TENS technically more difficult

 

Options

 

Plate v TENS

 

Xu et al. Medicine 2018 PDF

- no difference in outcome between plate and TENS

- plate patients tended to be older and heavier

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6086543/pdf/medi-97-e11568.pdf