Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

Pediatric Femoral Shaft Fractures

Overview

Pediatric femoral shaft fractures

• One of the most common causes of pediatric orthopedic hospitalization.
• Management depends on age, fracture pattern, fracture location, and the child’s weight.

Age Based Treatment Algorithm

Less than 6 months

• Pavlik harness.

6 months to 5 years

• Closed reduction and hip spica cast.
• Acceptable shortening is up to 2 cm.
• Shortening greater than 2 to 3 cm may require traction followed by delayed spica casting, although this is rarely used today.
• Avoid the 90 90 spica position because of the risk of compartment syndrome.

Special consideration

• Femoral shaft fracture in a non ambulatory child younger than 2 years should raise suspicion for non accidental trauma.
• Transverse fractures are particularly concerning.

5 to 11 years

• Operative management is usually preferred.

Flexible intramedullary nailing

• Best for diaphyseal transverse or short oblique fractures.
• Suitable for children younger than 11 years weighing less than 45 kg.
• Use two nails with a combined diameter equal to approximately 80 percent of the femoral canal.
• Most common complication is knee irritation at the entry site.
• Avoid in children older than 11 years, weighing more than 45 to 50 kg, or with length unstable fractures.

Submuscular plating

• Preferred for comminuted fractures.
• Suitable for proximal and distal shaft fractures.
• Bridge plating technique is commonly used.
• Aim for three screws proximal and three screws distal whenever possible.

External fixation

• Indicated for open fractures.
• Useful for polytrauma as damage control.
• Complications include knee stiffness and refracture after fixator removal.

Older than 12 years

• Rigid intramedullary nail.
• Submuscular plating when indicated.

Entry Point for Intramedullary Nailing

Preferred entry

• Lateral greater trochanter.

Avoid

• Piriformis fossa.

Reason

• Risk of injury to the medial femoral circumflex artery.
• May result in avascular necrosis of the femoral head.

Complications

Leg length discrepancy

• Most common complication.
• Usually due to overgrowth.
• Common in children younger than 10 years.
• Typically 0.5 to 2 cm.
• Occurs within the first two years after injury.

Loss of reduction in hip spica

• Risk increases with increasing initial shortening.
• One cm shortening has approximately 12 percent risk.
• Two cm shortening has approximately 24 percent risk.
• Three cm shortening has approximately 50 percent risk.

Malalignment

• More common after flexible intramedullary nailing.
• Up to 15 degrees of angulation may be acceptable depending on age.

Compartment syndrome

• Reduced by applying the body portion of the spica cast before the limb portion.

Traction pin complications

• Proximal tibial traction pins may cause tibial tubercle growth arrest.
• May result in genu recurvatum.

External fixation

• Increased risk of refracture after fixator removal.

Exam Pearls

• Less than 6 months: Pavlik harness.
• 6 months to 5 years: Hip spica cast.
• 5 to 11 years: Flexible intramedullary nails for length stable fractures.
• Comminuted or length unstable fractures: Submuscular plating.
• Open fractures or polytrauma: External fixation.
• Older than 12 years: Rigid intramedullary nail using a lateral greater trochanteric entry.
• Piriformis entry increases the risk of avascular necrosis of the femoral head.
• Most common complication is leg length discrepancy due to overgrowth.
• Flexible nails should not be used for length unstable fractures or in heavier children.

Key Take Home Message

• Treatment depends on age, fracture stability, fracture pattern, and patient size.
• Always assess length stability before selecting fixation.
• Lateral trochanteric entry is the preferred approach for rigid intramedullary nailing in adolescents.
• Most children heal well with appropriate treatment, but careful attention to alignment and limb length is essential for optimal outcomes.