Femoral Shaft



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.)

“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 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).





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.




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).






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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Nov 17, 2018 | Posted by in CARDIOLOGY | Comments Off on Femoral Shaft
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