Treatment for pediatric femoral shaft fracture varies.
Treatment can include casting or surgery, depending on the age of the patient
and the pattern of the fracture. A fracture of the femur that occurs in a child
before the walking age, there should be concern for non-accidental trauma,
suspect abuse. Pediatric patients 0-6
months of age should be treated with a Pavlik harness, 6months to 5 years of
age should be treated with an immediate spica cast. Moderate evidence supports
treatment with an early spica cast or traction with delayed spica cast for
children aged 6 mo. - 5 years with a diaphyseal femur fracture with less than 2
cm of shortening. A spica cast is not
used for a patient that has shortening of 2-3 cm. If there is excessive
shortening or potential shortening, there will be loss of reduction in the
spica cast and the child can be treated by traction and delayed spica cast or
by a different alternative. In very unstable fractures, you are going to use
traction with a delayed spica cast or external fixator. Children 5 years of age to 11 years, consider
using flexible rods, plate, or external fixator. To use flexible IM nails, the
fracture must be axially stable and it can be used in children between the ages
of 5-11 years, and should not be used in children weighing more than 100 pounds
or in children older than 11 years. An alternative technique, different than
the flexible IM nail should be used in older children that weigh more than 100
pounds or if the child is more than 11 years old. For the flexible nails to
work, the fracture must be short, oblique, or transverse. It is probably better if the fracture is in
the mid-diaphysis area. In comminuted fractures, or very distal or proximal
fractures, it may be hard to control the fracture with a flexible IM rod.
Approximately 50% of fractures treated with flexible nails have about 15
degrees of malalignment. The nail size
of the IM flexible nail is determined by multiplying the width of the isthmus
of the femoral canal by 0.4 and the goal is to have 80% fill. Sub muscular plate fixation can be used in
children more than 5 years old and in the patient that weigh more than 100
pounds. It can also be used in very proximal or very distal fractures where the
flexible rod will not work, especially if the fracture is unstable. It can be
used in cases of severe comminution when you will use the plate as a bridge
plate. It can be used for open fractures, if there is associated vascular
injury, if the fract5uer is significantly comminuted, or it can be used in
polytrauma patient. With external fixation there is increased risk of
re-fracture after removal of the fixator. The main blood supply to the femoral
head is the deep branch of the medial femoral circumflex artery and these
branches are near the piriformis fossa and are vulnerable to be injured with a
piriformis entry nailing. Osteonecrosis of the femoral head can occur with an
open proximal physis. Piriformis or near piriformis entry rigid nailing is not
usually recommended for the young child. If the IM rod needs to be done, it is
better to go through a greater trochanteric entry which can also have its own
complication such as coxa valgus or premature fusion of the greater trochanter
apophysis. Rigid trochanteric entry
nailing may be an option for children at or near skeletal maturity. The most common complication in younger
patients is leg length discrepancy with over growth of up to 2 cm in patients
younger than 10 years of age. It typically occurs within 2 years of the injury.
Leg length discrepancy can occur from excessive shortening following a cast
treatment. Do not accept more than 2 cm of shortening. Monitor the child for development of
compartment syndrome following spica cast. When you do traction and you delay
the spica cast, a proximal tibial traction pin can cause recurvatum due to
damage of the anterior part of the tibial tubercle apophysis.
