Editors: Swiontkowski, Marc F.; Stovitz, Steven D.

Title: Manual of Orthopaedics, 6th Edition

Copyright 2001 Lippincott Williams & Wilkins
> Table of Contents > 23 - Fractures of the Femur

Fractures of the neck of the femur in children (25,26,27)

o Treatment

Transepiphyseal fractures are uncommon, and there is no series of

sufficient size to make any conclusions about the treatment of choice. The
authors recommend reduction with capsulotomy and fixation with smooth
pins (27).

Undisplaced and minimally displaced cervicotrochanteric fractures carry a

risk of avascular necrosis. The pathophysiology may involve intracapsular
tamponade of the vessels supplying the femoral head (27). The authors
recommend capsulotomy, reduction if necessary, and fixation with lag
screws short of the femoral head epiphysis. The screws are generally
sufficient because of the density of the bone. In children 8 years old and
younger, postoperative spica cast immobilization is also used for 6 to 12
weeks. Displaced fractures are treated in the same way. These fractures
must be treated emergently to minimize the complication of avascular
necrosis.

Prognosis. These fractures have nearly a 100% rate of union with optimum
management.

Complications

Coxa vara. Although this complication is commonly reported, it is

generally associated with nonoperative management.

Avascular necrosis. This complication affects 0% to 17% of patients who

undergo emergent treatment. The long-term consequence is generally
degenerative arthritis, which requires total hip arthroplasty in patients in
their 40s to 60s.

Premature closure of the epiphysis occurred in 7% of the patients in Lam's

series (26). This complication is not a significant long-term problem
except when it occurs in children younger than 8 years.

VIII. Diaphyseal Femur Fractures in Children

For children younger than 6 to 8 years with an uncomplicated, isolated femoral shaft
fracture, a spica cast can be used for primary treatment. The technique is as follows (67):

When the patient's general condition has stabilized, usually after at least 24 hours
of observation in 2 to 3 lb of Buck's traction, the patient is placed under general
anesthesia on a fracture table. The feet are placed in stirrups, and traction is
applied. If necessary, a sling attached to an overhead bar may support the
fractured thigh to restore the normal anterior bow of the femur. For a
child younger than 2 years, it may be desirable to flex the hip and knee to 90
degrees. For the older child, the hip is flexed approximately 20 to 30 degrees,
abducted 20 degrees, and externally rotated to best align the distal fragment to the
proximal fragment. The knees are kept extended. Radiographs are made to verify
the reduction. The object of manipulation is to provide approximately 1 cm of
overriding of the fragments (bayonet apposition in good alignment in both
planes). When this position has been achieved, the skin between the knees and
ankles is then sprayed with medical adhesive. A single layer of bias-cut stockinet
is wrapped over the entire area as described for extremity casting (see Chap. 7).
Quarter-inch felt, sponge rubber, or several additional turns of Webril may be used
over bony prominences except between the knee and ankle. A double hip spica
cast is then applied, molded carefully around the pelvis, and extended to embrace
the rib margin. When the cast has hardened, the foot pieces of the fracture table
are removed, and if radiographs confirm the proper position, the cast is extended
to include both feet and ankles, which are well padded, in a neutral position. A
crossbar is added to the cast.

Postcasting treatment. Follow-up radiographs are made at 1, 2, and 3 weeks to be

certain of the maintenance of position. The cast is worn for 6 to 12 weeks,
depending on the age of the patient and the type of fracture. The family must be
instructed in cast care and told to alert the physician if there is any evidence of
pain, fever, or loss of extension of the great toe.

Children older than 8 years are not ideally managed with spica casts and usually receive
some sort of operative fixation. Antegrade interlocking nails, as used in adults, are not
appropriate in skeletally immature patients because of the risk of osteonecrosis of the hip.
For transverse, length stable fractures, retrograde flexible nailing has gained increased
acceptance (68). Trochanteric nails may be considered for the teenage child with fractures
of the diaphysis of the femur. The starting point for the nail should be moved slightly
lateral to decrease the risk of avascular necrosis. Compression plating remains a very
good option (69); percutaneous submuscular plating is another recent option.

Children with head injuries or multiple trauma should be managed with operative
stabilization. In patients younger than 12 years, this should involve plates, retrograde
flexible nails, or external fixators. Children older than 12 years may undergo treatment
with intramedullary nails.