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

 

Pediatric Femoral Shaft Fractures

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Overview

Pediatric femoral shaft fractures are among the most common major orthopedic injuries in children.

Management primarily depends on:

• Age of the child
• Fracture pattern
• Stability of fracture
• Weight of the child
• Associated injuries

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Important Clinical Red Flag

A femoral shaft fracture in a non-ambulatory child should raise strong suspicion for:

• Non-accidental trauma (child abuse)

Particularly concerning features include:

• Inconsistent history
• Delay in presentation
• Multiple fractures
• Associated injuries

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Deforming Forces

Understanding muscle forces helps predict fracture displacement.

Proximal Fragment

Typical deformities:

• Flexion
• External rotation
• Abduction

Muscles responsible:

• Iliopsoas
• Hip abductors

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Distal Fragment

Typical deformity:

• Shortening

Muscles responsible:

• Hamstrings
• Quadriceps

These muscles are biarticular and generate significant shortening forces.

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Age-Based Treatment Algorithm

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Infants (0–6 Months)

Preferred Treatment

Pavlik Harness

Advantages:

• No anesthesia required
• Easier nursing care
• Allows parental bonding
• Excellent remodeling potential

Disadvantages:

• Less rigid stabilization
• Initial muscle spasm possible

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Children (6 Months–5 Years)

Gold Standard

Early Hip Spica Cast

Best suited for:

• Stable fractures
• Shortening less than 2 cm

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Contraindications to Early Spica

Avoid isolated spica casting in:

• Unstable fractures
• Shortening greater than 2–3 cm
• High-energy injuries

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Alternative Options

• Traction followed by delayed spica
• External fixation in selected cases

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Proper Spica Positioning

Correct positioning is critical.

Recommended position:

• Hip flexion: 30–40°
• Hip abduction with external rotation
• Knee flexion: approximately 30°

Purpose:

• Relaxes iliopsoas
• Relaxes hamstrings
• Reduces shortening forces

Improper “anatomical” positioning may result in:

• External rotation deformity
• Angulation
• Persistent shortening

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Complications of Spica Casting

• Loss of reduction
• Malalignment
• Shortening
• Skin complications
• Compartment syndrome

Close follow-up is essential.

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Children (5–11 Years)

Multiple treatment options exist.

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1. Flexible Intramedullary Nails (TENs / ESIN)

Most commonly used technique in this age group.

Indications

• Age 5–11 years
• Weight less than approximately 45 kg
• Midshaft fractures
• Transverse fractures
• Short oblique fractures

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Not Ideal For

• Comminuted fractures
• Length-unstable fractures
• Very proximal fractures
• Very distal fractures

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Biomechanical Principle

Pre-bent elastic nails provide:

• Three-point fixation
• Relative stability
• Controlled micromotion

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Nail Size

Recommended diameter:

• Approximately 0.4 × medullary canal diameter

Goal:

• About 80% canal fill

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Technique Points

• Nails should be pre-bent
• Usually inserted retrograde
• Rotation must be checked clinically after fixation

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Complications

• Malalignment
• Shortening
• Nail migration
• Skin irritation

Up to 15° malalignment may occur.

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Preventing Shortening

Options include:

• End caps
• Third nail
• Alternative fixation methods

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2. Submuscular Plating

Useful for unstable fracture patterns.

Indications

• Comminuted fractures
• Length-unstable fractures
• Proximal fractures
• Distal fractures
• Heavier children (>45 kg)

Advantages:

• Better alignment control
• Suitable for difficult fracture patterns

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3. External Fixation

Indications

• Open fractures
• Polytrauma
• Vascular injury
• Severe soft tissue injury

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Major Complication

• Refracture after fixator removal

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Adolescents (>11 Years / Near Skeletal Maturity)

Options

• Rigid intramedullary nail
• Plate fixation
• External fixation

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Intramedullary Nailing

Important Surgical Principle

Avoid piriformis entry nails in children.

Reason

Risk of injury to:

• Medial femoral circumflex artery

This may lead to:

• Avascular necrosis (AVN) of femoral head

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Preferred Entry Point

Greater Trochanteric Entry

Safer regarding femoral head blood supply.

Possible complications:

• Coxa valga
• Premature greater trochanter apophyseal closure

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Skeletally Mature Adolescents

Adult-style antegrade intramedullary nailing may be used.

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Traction

Now less commonly used.

Types

• Skin traction
• Skeletal traction

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Limitations

• Prolonged hospitalization
• Muscle wasting
• Skin problems
• Difficult nursing care

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Complications of Pediatric Femoral Shaft Fractures

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1. Limb Length Discrepancy (Most Common)

Typically due to overgrowth.

Characteristics:

• More common in children <10 years
• Usually develops within 2 years
• Overgrowth may reach approximately 2 cm

Acceptable shortening at presentation:

• Up to 2 cm

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2. Malunion

More common with:

• Flexible nails
• Inadequate reduction

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3. Compartment Syndrome

May occur after:

• Spica casting
• High-energy trauma

Requires urgent recognition.

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4. Refracture

Especially after:

• External fixator removal

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5. Avascular Necrosis of Femoral Head

Associated with:

• Piriformis entry nails

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6. Growth Disturbance

May occur from traction pin placement.

Example:

• Proximal tibial traction pin causing recurvatum deformity

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Key Exam Pearls

• 0–6 months: Pavlik harness
• 6 months–5 years: Early spica cast
• 5–11 years: Flexible nails for stable fractures
• Older children/adolescents: Rigid fixation methods
• Avoid piriformis entry in children due to AVN risk
• Most common complication: Limb length discrepancy
• Femur fracture in non-walking child should prompt evaluation for child abuse