Fractures of Femoral Shaft - Orthopaedic Trauma - Lecture Slides, Slides for Orthopedics. Acharya Nagarjuna University
devaki21 December 2012

Fractures of Femoral Shaft - Orthopaedic Trauma - Lecture Slides, Slides for Orthopedics. Acharya Nagarjuna University

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Fractures of Femoral Shaft, Pediatric Femur Fractures, Osteonecrosis, Disruption of Blood Supply, Physeal Injury, Distal Femoral Physes, Trochanteric Apophysis, Fracture Subtrochanteric are some points from this lecture....
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Fractures of the femoral shaft in the pediatric patient

Fractures of the Femoral Shaft in the Pediatric Patient

Pediatric Femur Fractures

• 1.6 % all children's Fx’s • 28/100,000 child years (Holland) • 3:1 Male / Female ratio • Children >3 y.o.- highest incidence • Seasonal- highest summer

Treatment Goals - Restore

• Length • Alignment • Rotation

Treatment Goals - Avoid

• Osteonecrosis - disruption of blood supply to femoral head

• Physeal injury- preserve future growth potential (proximal and distal femoral physes, trochanteric apophysis)

Anatomy and Growth

• Proximal femoral physis- 30% of longitudinal growth

• Distal femoral physis- 70% of longitudinal growth

• Trochanteric apophysis- most of trochanteric growth appositional after age 8 years

Anatomy- Blood Supply Proximal Femoral Epiphysis

• Predominantly ascending cervical branch (B) of medial circumflex femoral artery

• Physis (D) - a barrier to intraosseous blood supply from femoral neck

Chung S. JBJS 58A, 1976

Pediatric Femur Fractures-Mechanism of Injury

• Rule out NAT in children <1year old • Falls- young children/toddlers • Struck by car- juvenile • Recreational sports/activities- adolescent • Motor vehicle crashes- all age groups

Mechanism of Injury

• Low Energy • High Energy *predicts

behavior/treatment of the fracture (Blount-1973, Pollack-1994)

Pediatric Femur Fractures- Associated Injuries

• Struck by car- triad of femur fracture, torso injuries, head injury

• Potential damage to physes of femur and proximal tibia

• Head Injury – spasticity can make traction and cast treatment difficult

• Abdominal injury – spica cast can constrict abdomen and limit ability to examine

Physical Exam

• Complete exam: head, chest, abdomen, and other skeletal segments

• Document distal neurologic and vascular function

• Palpate all bones • First Aid principles - Splint or traction,

especially prior to transfer to another institution

Radiographic Evaluation

• AP Pelvis • AP/Lat femur • Visualize hip & knee joints


• Open or closed • Location of fracture- subtrochanteric,

diaphyseal (proximal, mid, distal third), supracondylar

• Fracture pattern- transverse, spiral, oblique, comminuted, greenstick

• Amount of shortening • Angular deformity

7 Principles Dameron & Thompson JBJS 1959

• 1. Simplest treatment best • 2. Initial treatment permanent when possible • 3. Perfect anatomic reduction not essential

for perfect function • 4. More potential growth= more remodeling


Dameron & Thompson JBJS 1959

• 5. Restoration of alignment more important than fragment position

• 6. Overtreatment usually worse than undertreatment

• 7. Immobilize/splint injured limb before definitive treatment

Decision Making

• Age • Mechanism of injury • Fracture pattern & location • Associated Injuries • Surgeon preference

Traction Techniques

• Skin or skeletal • Avoid physes if place skeletal traction pins • Place pin perpendicular to shaft to avoid

varus/valgus angulation • Longitudinal in line traction for comfort prior

to definitive treatment • Split Russells traction (90-90) if awaiting early

healing prior to casting

Immediate or Early Spica Cast- Ideal Patient

• Less than 5 years old • Less than 100 lbs • Initial shortening not excessive • Isolated injury

• Note -Spica casts used for decades and can

work for almost any pediatric femur fracture

Spica Cast Technique

• Appropriate padding • Cast liners may decrease skin problems • Traction to get 0-15 mm shortening • Mold laterally to prevent varus • Can wedge for unacceptable angulation at

1-2 week checkups (>10-20° varus/valgus, >15-30° procurvatum/recurvatum – age dependent)

Immediate Spica Cast

• Fiberglass lighter, easier to x-ray through • Often strong enough to obviate need for

connecting bar • See Kasser AAOS Instructional Course Lectures

Volume XLI, 1992

Immediate Spica Cast

• X-ray weekly for 3 weeks • Time in spica = age in years + 3 weeks up to

maximum 8 weeks • Wedge cast for malalignment • Rotational alignment important at initial cast


AAOS Managing Orthopaedic Malpractice Risk 2000

• Closed treatment of children’s femur fractures resulted in the most frequent and expensive complications, including foot drop, skin loss, compartment syndrome, and malrotation / shortening.

Surgical Options

• Plate & screw fixation • External fixation • Flexible nailing • Rigid nailing

ORIF with Plates/Screws

• Advantages – rigid, technique familiar to most surgeons, allows early motion, favorable results reported in children with associated head injuries

• Disadvantages- large scar, possible refracture after plate removed, higher infection rate in some earlier series

External Fixation

• Advantages – can be applied rapidly, allows soft tissue injury management , early mobilization, avoid cast

• Disadvantages- pin site sepsis, pin site scarring, refracture, malunion

External Fixator Tips

• Appropriate size half pin diameter • Proper pin placement relative to fracture for

biomechanical rigidity • Do not remove ex fix until see bridging

cortices (3 or 4 of 4)

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