Courtesy: Amr Abdelgawad, Consultant, Maimonaides Medical Centre, Brooklyn, New York, USA

Pediatric Femur Fractures

Epidemiology

Pediatric femur fractures

Third most common long bone fracture after the forearm and tibia.
Incidence is approximately 30 per 100,000 children per year.
More common in males older than 3 years.

Mechanism of injury

Infants and toddlers: Falls. Always consider non accidental trauma.
Children aged 3 to 10 years: Pedestrian versus vehicle injuries.
Adolescents: Sports injuries.
All age groups: Road traffic accidents.

Clinical Assessment

Initial evaluation

Follow ATLS principles in high energy injuries.
Assess the head, chest, abdomen, and neurovascular status.
Remember that a femoral shaft fracture is a distracting injury and associated fractures may be missed.

Investigations

Radiographs

Obtain AP and lateral radiographs from the hip to the knee.
Always include the hip joint.
Always include the knee joint.
Include the pelvis to exclude an associated femoral neck fracture.

Classification

By location

Proximal.
Shaft (diaphyseal).
Distal (metaphyseal or physeal).

By fracture pattern

Transverse.
Spiral.
Oblique.
Comminuted.
Greenstick.

Non Accidental Trauma

Red flags

Femur fracture in a non ambulatory child.
Inconsistent history.
Delay in seeking medical attention.
Multiple fractures.
Changing history.

Important facts

Approximately 1 percent of children experience abuse each year.
Around 65 percent present with an isolated fracture.
Missed diagnosis is associated with approximately 5 percent mortality.
There is about a 25 percent risk of recurrent injury if abuse is missed.
Spiral fractures are not always due to abuse.

Management of Femoral Shaft Fractures

Children younger than 6 months

Pavlik harness.

Children younger than 4 years

Immediate hip spica cast.
Hip flexion of approximately 45 degrees is preferred.
Avoid the 90 90 spica position.

Children aged 5 to 12 years

Stable fractures

Flexible intramedullary nailing (TENS).

Indications

Midshaft fracture.
Transverse fracture.
Minimal comminution.
Weight less than 45 kg.

Unstable fractures

Submuscular plating.
Preferred for comminuted, proximal, and distal shaft fractures.

Children older than 12 years

Rigid intramedullary nail using a lateral entry point.

Special situations

Open fractures: External fixation.
Polytrauma: External fixation as damage control.
If image intensifier is unavailable: Open plating.

Treatment Modalities

Pavlik harness

Best for infants younger than 6 months.
Also useful for birth related fractures.

Hip spica cast

Standard treatment for children younger than 4 years.
Proper application is essential.
Ensure good perineal care.
Avoid excessive chest compression.

External fixation

Indications

Open fractures.
Polytrauma.

Disadvantages

High refracture rate of approximately 20 percent.

Flexible intramedullary nails (TENS)

Advantages

Minimally invasive.
Early mobilization.
Excellent for stable midshaft fractures.

Limitations

Comminuted fractures.
Obese children.
Proximal or distal shaft fractures.

Rigid intramedullary nail

Indications

Older children and adolescents.

Preferred entry

Lateral greater trochanter.

Complication

Avascular necrosis if piriformis entry is used.

Plating

Open plating

Provides rigid fixation.
Greater soft tissue dissection.

Submuscular plating

Biological fixation.
Minimal soft tissue disruption.
Preferred for unstable fractures in children aged 5 to 12 years.

Proximal Femur Fractures

Delbet classification

Type I: Transphyseal. Highest risk of avascular necrosis.
Type II: Transcervical. Approximately 70 percent risk of avascular necrosis.
Type III: Cervicotrochanteric.
Type IV: Intertrochanteric. Lowest risk of avascular necrosis.

Management

Emergency reduction and fixation.
Capsular decompression may be performed.
Fixation with screws, dynamic hip screw, or plate as indicated.
Hip spica may be required in selected cases.

Distal Femur Fractures

Types

Supracondylar fractures.
Physeal injuries.
Metaphyseal fractures.

Important points

Distal femoral physis contributes approximately 1 cm of growth per year.
Growth arrest occurs in about 50 percent of physeal injuries.

Management

Minimally displaced fractures

Cast or hip spica.

Physeal injuries

Urgent reduction.
K wire fixation if required, even across the physis when necessary.
Screws may be used if there is a large metaphyseal fragment.
Always assess for popliteal artery injury.

Exam Pearls

Younger than 6 months: Pavlik harness.
Younger than 4 years: Immediate hip spica cast.
Children aged 5 to 12 years with stable fractures: Flexible intramedullary nails.
Unstable or comminuted fractures: Submuscular plating.
Older than 12 years: Rigid intramedullary nail through a lateral entry.
Open fractures and polytrauma: External fixation.
Piriformis entry increases the risk of avascular necrosis.
Distal femoral physeal injuries have a high risk of growth arrest.
Delbet Type I femoral neck fracture has the highest risk of avascular necrosis.

Final Treatment Algorithm

Younger than 4 years: Hip spica cast.
Children aged 5 to 12 years with stable fractures: Flexible intramedullary nailing.
Children aged 5 to 12 years with unstable fractures: Submuscular plating.
Older than 12 years: Rigid intramedullary nailing.
Open fractures or polytrauma: External fixation.