Femoral Shaft Fractures in Children

Description
Femoral shaft fractures are defined as those >5 cm below the lesser trochanter, but above the distal metaphyseal (wider) portion of the lower femur. The location usually is specified as:
Proximal Midshaft Distal

Epidemiology
Fractures of the femur are more common:
In areas of high population density or low socioeconomic level In children 0-3 and 12-16 years old Represent 1.6% of all fractures in the pediatric population. Boys are more commonly affected at a ratio of 6:1.

MECHANISM OF INJURY
Direct trauma: Motor vehicle accident, pedestrian injury, fall, and child abuse are causes. Indirect trauma: Rotational injury. Pathologic fractures: Causes include osteogenesis imperfecta, nonossifying fibroma, bone cysts, and tumors.

Femoral Shaft Fractures

Femoral Shaft Fracture Classification

Descriptive Open versus closed Level of fracture: proximal, middle, distal third Fracture pattern: transverse, spiral, oblique, butterfly fragment Comminution Displacement Angulation

Femoral Shaft Fractures Clinical Features

Obvious deformity 50% have ligamentous instability of the knee Neurovascular injuries rare in closed fractures Fracture of Proximal 2/3
Proximal fragment abducted, flexed, and externally rotated due to pull of gluteal and iliopsoas muscles of trochanters

Fracture of Distal 1/3

Hyperextension of distal fragment due to pull of gastrocnemius

Treatment Options
Traction Spica Casting Pins & Plaster External Fixation Internal Fixation Plate/Screws Flexible nails Rigid Intramedullary rods - trochanteric vs. lateral entry

Operative Indications
Multiple trauma, including head trauma Open fracture Vascular injury Pathologic fracture Uncooperative patient Body habitus not amenable to spica casting

Femoral Shaft Fractures: 0 - 6 Months

Pavlik harness or a posterior splint is indicated. Traction and spica casting are rarely needed in this age group.

Femoral Shaft Fractures: 6 months - 5 years

Immediate spica casting is nearly always the treatment of choice (>95%). Skeletal traction followed by spica casting may be needed if one is unable to maintain length and acceptable alignment; a traction pin is preferably placed proximal to the distal femoral physis. External fixation may be considered for multiple injuries or open fracture

Femoral Shaft Fractures: 6 months - 12 years

Flexible intramedullary nails placed in a retrograde fashion are frequently used in this age group. External fixation or bridge plating may be considered for multiple injuries or open fracture. Some centers are using interlocked nails inserted through the greater trochanter (controversial). Spica casting may be used for the axially stable fractures in this age group.

Femoral Shaft Fractures: > 2 years

Intramedullary fixation with either flexible or interlocked nails is the treatment of choice. Locked submuscular plates may be considered for supracondylar or subtrochanteric fractures. External fixation may be considered for multiple injuries or open fracture

Complication
Early : Infection Vascular injury Compartment syndrome Late : Delayed union Malunion Nonunion