- Discussion:
- see
pediatric femur frx
- commonest site of fracture of the femoral shaft is in its middle third, where normal anterolateral bowing of diaphysis is at its maximum;
- torsional force produced by indirect violence results in a long spiral or oblique frx, whereas a transverse frx is caused by direct trauma;
- green stick frx are more common in the distal third;
- birth frx from OB trauma, usually occur in mid 1/3 & are transverse;
- excessive bleeding ( > 500 ml) or more is not uncommon;
- source of bleeding is usually the profundus femoris artery which course around femoral shaft, the vessels of
richly vascular muscles enveloping the femur, or the vessels in bone itself;
-
diff dx:
-
child abuse;
-
bone tumor
- be suspcious of femoral shaft fractures occuring from low energy trauma such as a football pile up;
- poor quality films may mask a
NOF,
UBC, or even osteosarcoma;
- Operative Considerations:
- children who have uncontrolled muscle spasticity, such as those w/
head injuries or severe cerebral palsy, do not tolerate external immobilization well;
- IM Nailing:
-
rigid nails:
- IM nailing using rigid nails may be indicated in children as young as 12-13 years;
-
position:
- consider placing the patient in the lateral position which will allow the hip to be flexed so that the guide wire can be placed posterior to the medius tendon;
-
entry hole for rigid nails:
- after the age of 7 most of growth to greater trochanter is appositional and not physeal (it has been observed that trochanteric growth arrest after age
7 will not correct congenital coxa vara);
- consider placement of the guide pin thru the medial 1/3 of the greater trochanter;
- note that
standard IM nail placement into the piriformis fossa may disrupt the posterior branch of the
MFCA;
- also note that insertion of the nail anterior to the piriformis fossa, may place the patient at risk for femoral shaft fracture;
- in the report by
Townsend DR and Hoffinger S (CORR 2000 Jul;(376): 113-8)) authors describe results of a technique in which the nail is
placed through the tip of the greater trochanter (avoiding the piriformis fossa and possible damage to
medial circumflex artery);
- between 1988 and 1995, the authors performed this procedure on 34 patients, who ranged in age from 10 - 17 years;
- there were no infections, nonunions, rotational deformities, or implant failures.
- 20 patients with open physes had a followup of 2 years or more.
- no patient had avascular necrosis of the femoral head develop.
- the authors recommend the trochanteric tip entry point for IM nailing in children;
- references:
Antegrade Intramedullary Nailing of Pediatric Femoral Fractures Using an Interlocking Pediatric Femoral Nail and a Lateral Trochanteric Entry Point
-
flexible nails: (see
synthes technique manual)
- may be indicated in children between 5-12 years of age for difficult fractures or for obese patients;
- in children older that 12 years of age flexible or rigid nails may be used depending on the circumstances;
- flexible pins are placed from the distal femoral metaphysis in a retrograde manner
- typically one pin is inserted medially and one is inserted laterally;
- in the study by E. Bar-on et al 1997, flexible IM nails were compared to external fixation in a prospective study;
- consisted of a prospective study w/ 20 patients w/ age ranges from 5-15 years;
- in their study, time to full wt bearing, ROM, and return to school were all faster in the flexibile nail group;
- nails were inserted from the proximal end for more proximal fractures and from the distal end for more distal fractures;
- there were no cases of limb length inequality nor malunion in the nail group;
-
controversies:
- time for nail removal spans between 6-12 months, when circumferential callus appears to
be solid and the fracture line is no longer visible;
- with early removal, there is a concern of a higher rate of malunion; (
Divesh Gulati, letter to the editor) (
E.J. Wall replies)
- references:
-
The operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails: a prospective analysis.
-
Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications.
-
Ender rod fixation of femoral shaft fractures in children.
-
Elastic stable intramedullary nailing of femoral shaft fractures in children.
-
Comparison of Titanium Elastic Nails with Traction and a Spica Cast to Treat Femoral Fractures in Children.
-
Complications of Titanium and Stainless Steel Elastic Nail Fixation of Pediatric Femoral Fractures
- Complications:
-
potential complications:
- include
avascular necrosis (as long as proximal physis is open) & risk of injury to trochanteric growth center;
- 13 yo male sustained femoral shaft frx which was treated w/ IM nail;
- one year later the patient developed AVN; (the nail was subsequently removed);
Interlocking intramedullary nailing of femoral shaft fractures in adolescents: preliminary results and complications. JH Beaty et al. J. Pediatric Orthopaedics. Vol 14. p 178-183.
Ligamentous instability of the knee in children sustaining fractures of the femur: A prospective study with knee examination under anesthesia.
SL Buckley MD et al. J. Pediatric Orthopaedics. Vol 16. No 2. 1996. p 206.
Premature greater trochanteric epiphysiodesis secondary to IM femoral rodding. EM Raney et al. J. Pediatric Orthop. Vol 13. 1993. p 516-520.
Intramedullary nailing of femoral fractures in adolescents. D. Buford Jr MD et al. CORR. No 350. p 85-89. May 1998.
Immediate percutaneous intramedullary fixation and functional bracing for the treatment of pediatric femoral shaft fracture.
Complications of titanium elastic nails for pediatric femoral shaft fractures.
Radiographic Changes After Lateral Transtrochanteric Intramedullary Nail Placement in Children.
Complications of Elastic Stable Intramedullary Nail Fixation of Pediatric Femoral Fractures, and How to Avoid Them.
IM of femoral frx in children through the lateral aspect of the greater trochanter using a modified rigid humeral IM nail: preliminary results of a new technique in 15 children.
Complications of Pediatric Femur Fractures Treated With Titanium Elastic Nails: A Comparison of Fracture Types.
Closed, locked intramedullary nailing of pediatric femoral shaft fractures through the tip of the greater trochanter.
Antegrade Versus Retrograde Titanium Elastic Nail Fixation of Pediatric Distal-Third Femoral-Shaft Fractures: A Mechanical Study.
Femur Fracture in Preschool Children: Experience with Flexible Intramedullary Nailing in 72 children.
Assessing leg length discrepancy following elastic stable intramedullary nailing for paediatric femoral diaphyseal fractures
