Femoral Shaft
Maya Pring
Peter Newton
INTRODUCTION
The femur is the longest and strongest bone in the human body, supporting over 11 times the body’s weight during running. Despite its strength, children find a wide variety of ways to break the femur. From coming through the birth canal to extreme sports such as flyboarding and parkour (Fig. 13-1), different stresses at all stages of development can cause a wide variety of injuries to the femoral shaft.
Surgeons who treat children’s fractures need to understand the nature of a femoral fracture in each age group and master treatment techniques that allow full recovery of structure and function (Fig. 13-2). Flynn and Curatolo have outlined five factors to consider and seven treatment options for pediatric femoral shaft fractures that we will
review in this chapter. (This chapter focuses on femoral shaft fractures—proximal femur fractures are discussed in Chapter 12 and distal femur fractures in Chapter 14.)
review in this chapter. (This chapter focuses on femoral shaft fractures—proximal femur fractures are discussed in Chapter 12 and distal femur fractures in Chapter 14.)
“Live as if you were to die tomorrow. Learn as if you were to live forever”
—Mahatma Gandhi
 Figure 13-1 Parkour (from French—parcours—“ course or route”) is a street sport in which the participant performs running, jumping, and climbing stunts using obstacles in any given environment. (Image by Cosmin Barbu https://www.flickr.com/photos/29541676@N06/4086706046.) |
 Figure 13-2 Each fracture must be treated differently based on the age of the child and the anatomy of the fracture. A. Spiral fracture in infancy, easy to hold in a cast. B. Proximal fracture in a 4-year old—more difficult to hold in a cast. C. Unstable shaft fracture in a teenager will require intramedullary fixation. |
ASSESSING THE PATIENT
A femur fracture in a non-walking child should set off warning bells for potential non-accidental trauma. Experts have stated that abuse may cause between 10% and 20% of all fractures in infants and toddlers; approximately 80% of all fractures caused by child abuse occur in children younger than 18 months. Be sure you are fully versed in suspecting and evaluating the potentially abused child (see Chapter 19).
Children who are walking but not yet involved in sports can fracture their femurs with lower energy twists and falls, getting the leg caught in a shopping cart, jumping off the couch, etc. The most common fracture type in this age group is a spiral fracture secondary to a twisting mechanism. Full exam should still be done, but the risk of child abuse and multiple injuries is much lower, and the child can often tell you a good story so you are not as dependent on the parents’ story.
Teen and young adult femur fractures often follow motor vehicle accidents, yet a vast array of extreme sports also that put them at risk for femur fracture and associated injuries (see Chapter 20). Deformity of the femur is often obvious, but it is important not to focus only on the femur and lose sight of other injuries that result from high-energy trauma such as spine, head, and internal organ injuries.
The femur fracture is often so painful that it masks other injuries (a so-called distracting injury). Following the normal ABCs of a trauma evaluation, a head to toe exam are critical both at the time of initial evaluation and following stabilization of the femur fracture. Monitor the blood pressure; shock is almost never the result of a femur fracture in childhood and is more likely because of internal hemorrhage (e.g., a ruptured spleen).
RADIOGRAPHIC ISSUES
Often the initial femur film is not of high quality, being one of many x-rays taken quickly in the emergency department as opposed to the more controlled setting of the radiology suite. Polytrauma patients can be difficult to position, and there are often more critical life-threatening issues that are being addressed, so true AP and lateral x-rays in the trauma bay are unusual. An oblique/rotated film can help you understand general fracture pattern, but overlap or the true extent of shortening is difficult to determine (Fig. 13-3). If the patient comes to the ED in a traction splint, or you put the patient in traction prior to going to the OR (we often use Buck or boot traction to keep the child comfortable), better x-rays may be obtained, although traction does pull the fracture more out to length making the initial shortening difficult to determine.
Before definitive treatment, you must image the hip and knee to avoid missing a hip dislocation, femoral neck fracture, or intra-articular knee injury. If there is question about the femoral neck or knee joint, CT is warranted, as these fractures even if non-displaced will substantially change your treatment plan.
Children may also sustain pathologic fractures from infection, bone cysts, fibrous lesions (Fig. 13-4), and very rarely malignant lesions. It is important to get a good history—do they (or anyone in the family) have a known bone disorder (osteogenesis imperfecta, fibrous dysplasia, neurofibromatosis), did the child have pain prior to the fracture, night pain, fevers, weight loss, etc.? Look at the child and x-rays carefully to avoid missing an underlying pathologic cause of the fracture. If there is any question, advanced imaging such as CT or MRI is warranted prior to surgical intervention (see Chapter 19).
CLASSIFICATION
In their AAOS Instructional Course Lecture in 2015, Flynn and Curatolo suggest the following practical classification of pediatric femur fractures:
Fractures that will heal with limited intervention
Fractures that should be treated without surgery but must be watched closely
Fractures that benefit from surgical intervention with load-sharing implants
Fractures that may benefit from surgical intervention with rigid fixation
Fractures in a patient with a limb at risk because of associated injuries (vascular, etc.) that require urgent treatment precedence
 Figure 13-3 A fracture may appear distracted or overlapping depending on the angle at which the radiograph is taken. |
 Figure 13-4 Pathologic femur fractures through a unicameral bone cyst, aneurysmal bone cyst, or fibrous lesions are not uncommon in children. This spiral fracture begins in a distal femoral lesion. |
 Figure 13-5 A deformity of the fracture will be based on the anatomic location of the fracture. |
“We mention traction, although it is rarely used as a definitive form of femur fracture management in the USA today”
Femoral shaft fractures can also be classified based on the following location:
Proximal (subtrochanteric)
Midshaft
Distal third
Depending on fracture level, the forces exerted on the fragments by the muscles that remain attached can pull the fracture into varus, valgus, flexion, extension, or rotational malalignment (Fig. 13-5). These forces must be considered and counteracted by the cast, traction, or internal fixation when planning treatment. Poorly applied treatment of any type can worsen the initial deformity and create an unacceptable result.
TREATMENT
The seven options for treating femoral fractures in children, as organized by Flynn and Curatolo, include the following:
Pavlik harness with or without a splint
Walking hip spica cast
Standard spica cast with or without traction
Elastic intramedullary nailing
Submuscular plating
External fixation
Trochanteric-entry intramedullary nailing.
We mention traction, as noted in (3) above, although it is rarely used as a definitive form of femur fracture management in the United States today. However, there are many parts of the world where traction is the
mainstay of femoral fracture treatment for all ages including adults. If you do outreach trips to countries that don’t have advanced resources and equipment, placing a patient in traction may be safer than implanting metal with the risk for infection and non-union.
mainstay of femoral fracture treatment for all ages including adults. If you do outreach trips to countries that don’t have advanced resources and equipment, placing a patient in traction may be safer than implanting metal with the risk for infection and non-union.
TECHNIQUE TIPS: Traction
Skin Traction
For patients less than 60 pounds.
Apply adhesive to the skin.
Pad malleoli and fibular head with cast padding.
Apply traction tape (fabric backed foam) down medial and lateral sides of the legs.
Overwrap the tapes from ankle to knee leaving the foot free.
Use no more than 5 pounds of weight.
Use sling and pillow to support the hip and knee in a slightly flexed position (20-30 degrees).
Check skin regularly, as skin blistering and sloughing can occur.
Regular neurovascular checks—nerves and blood vessels can be compromised.
Traction can be used until there is adequate callus for spica.
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Skeletal Traction
For patients greater than 60 pounds (can be used on adults as well as children).
The distal femur is preferred for insertion of the Steinmann pin (tibial pins may sublux the tibia or injure the physes, including the tibial tubercle).
Pins may be threaded (better hold) or smooth (easier to insert and remove).
Pins inserted from medial to lateral to protect the neurovascular structures, entry point is proximal and parallel to the physis in the metaphyseal flare.
During pin insertion, hold the leg in the position for traction (usually 90-90) so the skin and fascia are not stretched after pin insertion.
Apply dressing over pins, followed by a traction bow.
A short leg cast with anterior loops allows rotational adjustment and prevents equinus contractures.
Apply enough weight to support the leg, avoid over-distraction at the fracture site.
X-rays in traction should be checked weekly to allow proper adjustment of weight and position to ensure that there is no distraction at the fracture site and that alignment remains acceptable.
Traction can be used until there is adequate callus for spica (good test: no pain with thigh motion—usually 3 weeks).
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 Figure 13-6 For quick transport of a patient with a femur fracture, a Hare traction splint can be used to keep the fracture out to length. These splints cannot be used for more than a few hours, as there is a risk of skin necrosis and tourniquet effect at the ankle. The proximal pad pushes against the ischium while traction is pulled through the ankle cuff. |
One to three kilograms of skin traction can be used for a short period of time before placing the child in a spica. If greater force is required to get an adequate reduction, skeletal traction should be considered. If the distal femoral physis is still open, the traction pin must be placed proximal to the femoral physis to avoid physeal injury. Skeletal traction can be used for many weeks until the fracture is healed (see Technique Tips), but if possible, it is better to get patients out of bed and back to school or work.
If a patient comes to the hospital in a traction splint put on in the field by EMTs (Hare traction splint, Thomas splint, Sager splint, etc.) (Fig. 13-6), the splint should be removed as soon as possible. These splints keep the fracture out to length and decrease discomfort and hemorrhage during an ambulance or helicopter ride, but they are not meant for longer-term use. Do not leave a patient in a traction splint overnight, as there is risk for skin breakdown and nerve injury.
In addition to available resources, the age of the child, mobility, weight, fracture “personality” (location, pattern, and stability), and surgeon skill will all influence the best treatment for a particular child.
THE NON-WALKING CHILD
Fractures in children under 2 years heal quickly and have great potential to remodel; a good outcome is almost certain in very young children regardless of shortening or initial alignment. Most are classified as Class 1: fractures that heal with limited intervention. The goal of treatment is comfort while the fracture heals. Surgery is almost never necessary (the extremely rare exceptions being an open fracture or fracture with neurovascular compromise).
A Pavlik harness with a soft wrap around the thigh (we use cast padding) may be easier for a parent to manage for diaper changes and nursing than a spica cast and can be considered for infants up to
6 months of age. This is particularly useful in the NICU where a spica would make monitoring and care of the child very difficult (Fig. 13-7).
6 months of age. This is particularly useful in the NICU where a spica would make monitoring and care of the child very difficult (Fig. 13-7).
 Figure 13-7 This infant was treated in a Pavlik harness and had quick healing and remodeling of her fracture. |
It is important to remember that the Pavlik does not prevent motion at the fracture site, so the baby must be moved very carefully—typically they will not move their own leg when it hurts, but diaper changes may be quite painful if the caretakers are not aware and gentle. You should assess the parents and choose a treatment method that they can manage. A splint gives a little extra immobilization and decreases pain; a spica gives excellent immobilization that makes a femur fracture relatively pain free while it heals. Three to four weeks of immobilization is typically adequate for children under 2 years of age.
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