Paediatric femoral shaft fracture

Always consider and actively exclude Non accidental injury (NAI).

No fracture pattern is particular for NAI ensure history is compatible with injury and infants development. Infants not yet crawling or walking be very suspicious. An infant of walking age, with isolated femoral fracture is more likely to be accidental than non-accidental injury.
Treatment is either traction or spica cast, or combination of both.

Traction

Bryant’s or gallows traction - Do not use for children older than 18 months, best for infant under 1 year. Weight limit of child 16-18Kg.

Lie child supine with the hips flexed 90°, the legs being pulled directly upwards. Apply only enough weight or elevate the infant just enough to allow you to slip your hand under the nappy.

Gallows traction has been associated with vascular problems, including severe compartment syndrome and Volkmann’s ischaemic contracture. This is due to the elevated position of the legs, straightness of the knees and tightness of bandages.

Avoid complications, apply the traction carefully, use adhesive skin traction, allow some knee flexion and don't bandage too tight.

Examine the skin daily release bandages but not disturbing the adhesive traction.

Older/ heavier infants can be managed with straight leg traction, either in the horizontal position with the foot of the bed slightly elevated, or on an inclined

plane.

Hip Spica

Commence on traction initially then discuss with parents option of converting to early spica cast. This depends a lot on the paediatric anaesthetic service.

It is possible to convert to late spica without GA once fracture "sticky", however in the infant age group a femoral shaft will heal in 2–3 weeks, the time between the fracture being sticky enough for delayed casting and full union may be quite small, rendering the application of a cast unnecessary.

Spica cast management increases the burden on the parents depending on the size of the infant.

In neonates and infants up to the age of three months, the Pavlik harness is a useful device for managing femoral shaft fractures that leads to a satisfactory outcome.

2. Toddlers and small children (18 months - 4 years)

Non operative treatment is the mainstay of treatment.

Gallows traction is inappropriate, traction either straight on the bed or over a pillow, in a splint, or on some form of balanced traction, such as Hamilton-Russell traction.

Skeletal traction is not required, adhesive skin traction is sufficient.

Hamilton-Russell traction has the advantage of controlling rotation and preventing the external rotation deformity that can occur with skin traction, as the leg tends to fall into external rotation.  Early knee flexion will help control rotation.

Traction rule of thumb:

• Traction weight; one pound of weight (0.5 kg) per year of life.

• Traction duration; one week per year of life

Once again the option of conversion to hip spica exists applied early or late.

Fractures that have considerably shortened might be best managed on traction followed by late hip spica to prevent too much shortening. (Perhaps accept a little shortening remembering compensatory overgrowth).

Early hip spica application allows shorter duration in hospital. Length and alignment of the femur are maintained by flexing both the hip and the knee and moulding the cast in these places.

If applying an early hip spica ensure:

• The parents are reliable

• The fracture is not complicated

• Child less than 8

• Child fit for General anaesthetic

Monitor regularly for angulation and shortening. Shortening more than 15 mm in the early stages of hip spica treatment is unacceptable and traction should be resumed. Angulation – 15° of varus/ valgus angulation and 25°of flexion or extension can be accepted in this age group due to extensive remodelling potential.

Several treatment options exist:

1. Traction

2. Hip Spica

3. Elastic stable intramedullary nailing (ESIN) (TENS)

4. External fixation

5. Plate fixation

1. Traction

Simple skin traction rarely lasts more than 6 weeks, consider applying a traction pin.

If you are subjecting a child to a General anaesthetic to insert a traction pin, perhaps you should consider operative stabilisation.

Traction pins can be placed in the distal femur or proximal tibia ensure you avoid the physis.

The scars of elastic stable intramedullary nailing ESIN are only slightly bigger to those of a traction pin and are probably a better option to a traction pin.

2. Hip Spica

It is possible to use a hip spica to the age of 8, but it is very cumbersome in the older child for carer and child.

Disadvantages include skin care, hygiene, education, mobility. Social isolation can be  a problem it is difficult to get a 6 year old around in a hip spica.

Education, an 8 year old in a hip spica may get the child home and out of the hospital. However a regular school will not be able to accomodate him/her and they will be off school for a term ( 8weeks).

3. Elastic Stable Intramedullary nailing

When performed well this is the best method for stabilizing femoral shaft fractures in this age group.

See Tens nails for technique.

4. External fixation

This was a popular in the late 70s early 80s, since ESIN has become available external fixation is being used less.

Problems with pin site infection, unattractive pin site scars, slow time to union and re fracture rate limit the value of external fixation over ESIN.

External fixation has some advantages of  ease of application and the fact that, in the older child at least, removal can be performed without general anaesthesia.

It has been suggested that external fixators be left on for 10–12 weeks until union is solid to prevent excessive re-fracture.

Refracture following removal is a real problem, one theory is the construct is too rigid and as such use only 4 pins, maximum 6.

Late dynamisation of a very rigid frame has not been shown to speed up healing with more callus, whereas an initially less rigid frame will.

External fixation of femoral fractures in this age group has a role to play in polytrauma patients and patients with severe soft tissue injuries not amenable to ESIN. (remember ESIN stability rests partly on the integrity of the soft tissues).

5. Plate fixation

The advantages of plate fixation are that it can be done without fluoroscopy and it offers excellent control of proximal shaft fractures, which can be difficult to manage with both elastic nailing and external fixation.

Disadvantages include substantial exposure, with at least some muscle stripping and devascularisation of bone and for many children a lengthy scar is a considerable issue.

Plate removal would require another extensive operation and the residual screw holes are a considerable risk for re-fracture. For these reasons, plating has generally been reserved for situations where its advantages were paramount, such as the head-injured child being operated on in the neurosurgical theatre or in the treatment of polytrauma, allowing other fractures to be fixed concurrently.

Recently, there has been a considerable trend in both adult and children’s practice towards minimally invasive plate osteosynthesis (MIPO). This procedure has the

advantages of reducing the scar and leaving the soft tissue envelope more intact, but risks inexact fixation and the possibility of leg lengthening. Leg length

discrepancy has been variably reported after plate fixation. The most common cause of lengthening after plate fixation is likely to be lengthening at the

time of surgery and this is inherently more of a risk if the fracture site is not visualized.

4. Older children/adolescents

Non operative treatment.

As a child approaches adulthood, non operative treatment becomes increasingly inapproriate. Hip spica cast application is impossible and traction often requires a skeletal pin and considerable time. To avoid malunion, shortening and rotational deformity careful attention needs to be paid when using traction.

Operative treatment

1. Elastic stable intramedullary nailing

2. Plate fixation

3. Locked intramedullary nailing (Trochanteric entry point)

4. External fixation

1.Elastic stable intramedullary nailing

For technique see TENS nailing

The concern about elastic nails is whether they are strong enough to stabilise the fractures of heavier children. In general ESIN is possible in children less than 60Kg. In overweight children consider a period of bed rest or a femoral brace.

2. Plate fixation

Either standard plating or Minimally Invasive Plate Osteosynthesis (MIPO)

Plate configurations that achieve relative stability are most appropriate for adolescents with good results reported.

3. Locked intramedullary nail

The use of conventional adult antegrade intramedullary nails  remains controversial.

It has been shown to be effective in maintaining length, alignment and progress to union.

The blood supply of the femoral head prior to physeal fusion almost entirely depends on the lateral ascending branch of the medial femoral circumflex artery, which becomes the lateral ascending cervical artery. This artery penetrates the lateral capsule in the trochanteric fossa, passing between the trochanter and the capsule and passing very close to the piriformis fossa.

It is therefore at considerable risk from straight intramedullary nails that utilise a piriformis fossa entry point or one which starts on the medial part of the greater trochanter and whose insertion involves reaming out the medial wall of the greater trochanter.

Lateral trochanteric entry points are safer but can not guarantee to avoid this complication.

The incidence in adolescents approaches only 1-2%, however it is a devastating complication as there is no good solution for Avascular necrosis in an adolescent.

Some surgeons will still advocate locked intramedullary nailing with meticulous technique and lateral trochanteric entry point.

Others advocate avoidance of locked intramedullary nailing prior to physeal closure (and indeed immediately afterwards). This is because avascular necrosis of the femoral head is a crippling condition and the majority of children can be successfully treated with elastic nailing, external fixation or plating.

There are certain circumstances in morbidly obese adolescents eg. 120Kg where a locked intramedullary nail might be considered prior to physeal closure. It is important to ensured informed consent referring particularly to the 1-2% incidence of avascular necrosis and the future consequences.

4. External fixation

Issues are similar to those of the 4-12 year age group (ex fix 4-12 years)