Treatment Options in Pediatric Femoral Shaft Fractures
Fracture of the femur in a pediatric patient presents special problems, and a variety of treatment options. Child abuse and neglect should be considered and evaluated. Fractures in infants (0-18 months) may be treated successfully in a Pavlik Harness. Spica casting is safe and effective in children up to about 6 years or 100 pounds, although complications can occur and careful attention to technique is important. Surgical treatment is superior in most older or larger children or adolescents, and in cases of multiple trauma, soft tissue injury, obesity or head injury. External fixation is minimally invasive, but carries a risk of malunion and refracture. Rigid antegrade intramedully nailing is possible in adolescents of accept- able size, but has a risk of avascular necrosis. Flexible nailing is minimally invasive and well suited to fractures of the central 2/3 of the diaphysis. In comminuted fractures, it may require supplemental external support. Plate fixation is stable and addresses the entire length of the femur. Soft tissue concerns due to surgical exposure can be minimized by the use of submuscular placement technique.
Available from: Sauli Palmu
- "Although there have been numerous studies describing different operative treatment methods, there is still no consensus as to which method should be used (Sanders et al. 2001, Flynn and Schwend 2004, Hedin 2004, Anglen et al. 2005, Cummings 2005, Wright et al. 2005, Poolman et al. 2006). Femoral fracture treatment may lead to various complications such as malunion, non-union, leg-length discrepancy, skin lesions, and nerve injuries (Yandow et al. 1999, Flynn and Schwend 2004, Anglen and Choi 2005). Persistent angular deformity of the lower limb may lead to premature arthritis (Eckhoff et al. 1994). "
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ABSTRACT: Background and purpose
During the past decades, treatment of pediatric femoral fractures in Finland has changed from mostly non-operative to more operative. In this retrospective study, we analyzed the long-term results of treatment.
Patients and methods
74 patients (mean age 7 (0–14) years) with a femoral fracture were treated in Aurora City Hospital in Helsinki during the period 1980–89. 52 of 74 patients participated in this clinical study with a mean follow-up of 21 (16–28) years. Fracture location, treatment mode, time of hospitalization, and fracture alignment at union were assessed. Subjective assessment and range of motion of the hip and knee were evaluated. Leg-length discrepancy and alignment of the lower extremities were measured both clinically and radiographically.
Of the 52 children, 28 had sustained a shaft fracture, 13 a proximal fracture, and 11 a distal fracture. 44 children were treated with traction, 5 by internal fixation, and 3 with cast-immobilization. Length of the hospital treatment averaged 58 (3–156) days and the median traction time was 39 (3–77) days. 21 of the 52 patients had angular malalignment of more than 10 degrees at union. 20 patients experienced back pain. Limping was seen in 10 patients and leg-length discrepancy of more than 15 mm was in 8 of the 52 patients. There was a positive correlation between angular deformity and knee-joint arthritis in radiographs at follow-up in 6 of 15 patients who were over 10 years of age at the time of injury.
Angular malalignment after treatment of femoral fracture may lead to premature knee-joint arthritis. Tibial traction is not an acceptable treatment method for femoral fractures in children over 10 years of age.
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ABSTRACT: The proximal humerus tends to fracture into four distinct fragments: the humeral shaft, the greater and lesser tuberosities,
and the articular surface.1 Neer based his classification system on displacement of these fragments by greater than 1 cm or angulation of more than 45°.
In a retrospective review, Neer found that 85% of fractures were considered to be minimally displaced and nonoperative management
led to satisfactory results. Displaced two-part greater tuberosity fractures, according to the above criteria, were treated
with open reduction and internal fixation.1,2
Several authors, however, have advocated treatment that is more aggressive for fractures of the greater tuberosity. Five millimeters
of displacement, particularly in the superior direction, has been suggested as an indication for operative management.3–5 The major deforming forces on the greater tuberosity are the supraspinatus, infraspinatus, and teres minor, resulting in
superior and/or posterior pull of the fragment. Malunion with superior displacement may lead to painful impingement and posterior
displacement may result in loss of external rotation, which can be challenging to treat.6–8
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ABSTRACT: Complex, high-energy pediatric femur diaphyseal fractures cannot be treated reliably by conventional methods: casting is not suitable for polytrauma and large children, external fixation is associated with a high rate of malalignment and refractures, elastic nails are unsuitable for unstable fractures and metaphyseal areas, and lateral trochanteric entry rigid nails cannot address proximal and distal fragments and need relatively large medullary canals. A few centers have reported that submuscular bridge plating (SBP) is associated with minimal complications, but these findings require confirmation. We asked whether SBP (1) reproducibly leads to union in unstable fractures with a low complication rate, (2) leads to reasonable alignment and leg length equality (3), is unaffected by age, weight, or location of fracture, and (4) is associated with no or minimal refracture after hardware removal. We retrospectively reviewed 60 fractures in 58 patients with pediatric diaphyseal femoral fractures treated with SBP from 1999 to 2011. The average age was 9 years. Forty (67%) of the fractures were unstable. Minimum followup was 2.4 months (average, 15.5 months; range, 2.4-50.6 months). All fractures healed well and all patients returned to full activity. Two of the 58 patients (3%) had major complications leading to unplanned surgeries: one implant failure and one deep infection in an old open fracture. None of the patients developed clinically important malalignment or leg length discrepancy. Implant removal was performed in 49 patients without complications. SBP provided reliable fixation and healing for complex pediatric femur fractures and can have a broader application in the orthopaedic community. SBP is our preferred method for unstable fractures or fractures of the proximal and distal shaft.
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