American Academy of Orthopaedic Surgeons 1999 Annual Meeting Scientific Program

Femoral Fractures in Children and Adolescents: Consensus and Controversy

Monday, February 8, 1999
10:30 AM - 12:30 PM

Location: A1

SYMPOSIUM

James R Kasser, MD, Boston, MA
Scott J Mubarak, MD, San Diego, CA
Charles Turner Price, MD, Orlando, FL
William W Robertson Jr, MD, Washington, DC
John F Sarwark, MD, Chicago, IL

Femoral shaft fractures are relatively common injuries in children and adolescents. In children 6 to 10 years of age and in older adolescents, treatment indications for isolated femoral shaft fractures often overlap. Spica casting, external fixation, flexible intramedullary nailing, locked intramedullary nailing, and compression plating all have been recommended in various age groups, making treatment decisions difficult. Faculty with experience in each type of treatment will discuss indications and contraindications, advantages and disadvantages, technique pearls and pitfalls, outcome, complications, and cost analysis of the various methods. Emphasis will be on choosing the most appropriate treatment method for each individual patient.

1. Outcomes, Cost Analysis and Femoral Fracture Management
   Scott J. Mubarak, MD, San Diego, CA
2. Spica Casting for Femoral Fractures in Children: Selection, Technique, Complications
   John F. Sarwark, MD, Chicago, IL
3. External Fixation of Femoral Fractures: Technique Tips, Complications
   Charles T. Price, MD, Orlando, FL (c - EBI, Inc.)
4. Compression Plating of Femoral Fractures in Children and Adolescents
   William W. Robertson, Jr, MD, Washington DC
5. Flexible IM Rods in Femoral Fractures: Technique, Results, Complications
   James R. Kasser, MD, Boston, MA
6. IM Nailing of Femoral Fractures in Adolescents: Technique, Results, Complications
   James H. Beaty, MD, Memphis, TN

Case Presentations and Discussion

Outcomes, Cost Analysis and Femoral Fracture Management

Outcome must be assumed to be equal for financial analysis; however, all treatments will have different effects on patient, parents, and physicians.

Terminology

• Charges (billing)
• Collections
• Cost

Who charges for their services ?

• Hospital
• Outpatient
• Physicians
  • Orthopaedist
  • Anesthesiologist
  • Radiologist

How much does it cost ?

• Early spica
• Skin traction and spica
• Skeletal traction and spica
• External fixation
• Intramedullary rod
  • Rigid
  • Flexible
• Metal removal

What happens when the rules change ?

• Fee for service
• Discounted fees
• Case rate
• Capitation

Spica Casting For Femoral Fractures In Children: Selection, Technique, Complications

Mechanism of injury

• Higher energy trauma --> more displacement
  • Automobile-related accidents
  • Falls from high places Other high-energy trauma
• Lower energy trauma --> less displacement
  • Lesser falls
  • Torsion injuries (accidental)
• Less common causes
  • Osteogenesis imperfecta
  • Myelomeningocele
  • Cerebral palsy
  • Metabolic disorders
  • Benign skeletal lesions

General treatment considerations

• Chronological age
• Bone age
• Size of child
• Cause of injury
• Isolated injury vs polytrauma
• Socioeconomic factors

Assessment for early spica cast

• Low-energy trauma
• Initial film - initial shortening < 1.5 cm
• Telescope test, evaluation under anesthesia with shortening < 1.5 cm

Early spica cast (or traction + spica cast)

• Pros
  • Avoids risks of external fixation
  • No surgical intervention
• Cons
  • Time in traction
  • Pin track problems
  • Total time and costs to family
  • Decreased mobility
  • Difficulty in high-energy trauma
• Pearls and pitfalls
  • Outline the pin track on anterior thigh with fluoro-scopy before placing pin
  • "Obliquely placed femoral pin --> increased risk of varus/valgus angulation
  • Pins should be parallel to axis of knee joint
  • Excessive late shortening may require re-admission, traction and/or osteoclasis
• Technique of spica cast application
  • 1½ hip spica cast - knee is bent 45° - 60°
  • Increasing flexion/abduction with increasing proximal location of fracture
    Distal 1/3 - full extension
    Mid 1/3 - 30¡ flexion, 15¡ abduction
    Proximal 1/3 - 45¡ flexion, 30¡ abduction
  • Apply spica portion at level below knee in one application, then extend to foot
  • Sole of cast at foot can be removed

Evaluate under anesthesia

• Shortening > 1.5 cm --> traction/spica or IM nail or ??
• Exception - polytrauma --> external fixator

Protocol now: Discuss with parents, offer options

External Fixation of Femoral Fractures: Technique Tips, Complications

Introduction

• There are many ways to treat pediatric femoral fractures
• Of 47 orthopaedic malpractice judgements in 1996, 5 (10%) were pediatric femoral fractures (AAOS Bulletin)

Management depends on

• Age of patient
• Severity of trauma

Cast immobilization for

• Younger children
• Stable fractures

Operative stabilization for

• < 6 years for severe trauma
• 6 - 10 years for moderate to severe trauma, social considerations
• > 10 years for all femoral fractures

Telescope test - age 6 - 10 years

• General anesthesia
• Gentle shortening compression
• Consider cast if < 3 cm overlap

Alternatives to early spica

• 3 weeks of traction, then cast
• Home traction
• Traction casting with pins
• Surgical stabilization

Advantages of external fixation

• Portable traction
• Simple application
• Avoids fracture site
• Avoids growth plates
• Simple removal

Problems with external fixation

• Acceptance by patients
• Delayed union and re-fracture
• Pin track problems

Re-fracture

• Related to fracture pattern; most likely with
  • Transverse and oblique
  • End-to-end reduction
• Related to fixator stiffness
  • Too stiff --> stress shielding --> poor callus
    More screws
    Larger screws
    Wider screw spacing
    Fixator closer to shin
  • More elastic --> good callus, but angulation possible
    Fewer screws
    Smaller screws
    Tighter spread of screws
    Screws farther from fracture
    Fixator farther from skin

Callus fromation

• Usually excellent with
  • Comminuted fractures
  • Metaphyseal fractures
  • Bayonet apposition of shaft fractures
• Dynamize at 4 - 6 weeks

Pin track management

• Peroxide pin care for 2 weeks
• After 2 weeks, soap and water, whirlpool, chlorinated pool
• Oral antibiotics for inflammation or drainage
• Very rarely, remove screws or use IV antibiotics

Scars

• Not same as scars from lengthening
• Easily and superficially revised
• Scar revision easier than nail or plate removal

When to use external fixation for femoral fractures

• Comminuted fractures
• Metaphyseal fractures
• Open fractures

Compression Plating of Femoral Fractures in Children and Adolescents

General

• Femoral shaft fractures frequent in children adolescents
• Guidelines for treatment vary
  • Patient's age
  • Patient's size
  • Fracture pattern
  • Associated injuries
  • Social circumstances
• Rising costs are impetus to get the child home quickly

Treatment for children 8-12 years old - all can obtain good results

• Traction followed by spica casting
• Flexible IM nailing
• Plating
• External fixation

Primary indications for surgical treatment

• Polytrauma
• Severe head injury
• Open fracture

Rigid internal or external fixation

• Advantages
  • Simplified nursing care
  • Rapid mobilization
• Disadvantages
  • Another surgery
  • Pathologic fracture
  • Leg lengthening

Our study

• August 1993 - February 1996 - retrospective case review
• 21 children, aged 8-12 years (average 10 years) 13 boys, 8 girls
• 23 femoral shaft fractures treated with compression plating
• Mechanism of injury
  • Pedestrian struck by motor vehicle - 12
  • Passenger in motor vehicle - 3
  • Sports injury - 3
  • Bicycle accident - 2
  • Fall from second-story window - 1
• Three open fractures (pedestrians struck by cars)
  • Two grade II fractures
    One isolated
    One with contralateral humeral shaft fracture, multiple organ injuries
  • One grade IIIC fracture
    Transection of superficial femoral artery
    Compartment syndrome
• Fracture site
  • Proximal 1/3 - 3
  • Middle 1/3 - 11
  • Distal 1/3 - 9
• Fracture configuration
  • Transverse - 13
  • Oblique or spiral - 10
• Other fractures
  • Isolated femoral shaft - 11
  • Other long bone fractures - 5
  • Multiple organ injuries, +/- other bone injuries - 5
• Open reduction and internal fixation within 3 days of injury
  • 4.5-mm broad dynamic compression plate
  • Interfragmentary screws whenever possible
  • 8-hole plates used most often (range 6 - 9)
  • At least one of central holes in plate not filled with screws in 7
  • Bone grafting was not used
• Length of hospital stay
  • Isolated femoral shaft fractures (11) - 3.3 days (range 2-5 days)
  • Other long bone fractures (5) - 5.4 days (range 4-7 days) Multiple organ injuries (5) - 17.8 days (range 11-26 days)
• Postoperative management
  • No casts
  • Crutches/toe touch
• Average follow-up of 16 months (range 6 -30 months)
• Three patients had follow-up of less than 12 months
  • Two lost to followup at 6 months - fractures healed
  • One lost to followup at 8 months - plate removed at 6 months, doing well
• Results
  • Callus formation - 6 weeks (range 4 - 12 weeks)
  • Weight-bearing to tolerance (radiographic healing) - 8 weeks (4-12 weeks)
  • All radiographically and clinically healed at 1-year follow-up
  • None developed leg length discrepancy
  • Hardware removed in 11 at average of 12 months (range 6-16 months)
    No complications or re-fractures
• Complications
  • Hardware failures after initial surgery - 2
    One treated in hip spica for 7 weeks
    One plate replaced with 9-hole plate
  • No infections, nonunions, malunions, or growth disturbances
  • Minimal scar

Advantages of plate fixation

• Anatomic reduction
• Good control of fracture
• Simplified nursing care
• No leg-length discrepancy

Flexible IM Rods in Femoral Fractures: Technique, Results, Complications

The rod

• Titanium (Nancy)
  • 2 - 4 mm in diameter
  • Large "elastic" range
• Stainless (Ender)
  • More rigid
  • Less elasticity
  • Greater strength

Biomechanics of fixation

• Fracture rigidity is much less than with external fixation or locked IM rod
• Callus formation is enhanced relative to rigid internal fixation
• Increased flexiblity leads to possible shortening, angulation, and rotational deformity

Technique

• Determine the level of the fracture
• Place a 40° bend in the rod at the anticipated area of the rod that will correspond to the level of the fracture
• Bend the tip of the rod to make insertion easier
• Insert the rod through a metaphyseal hole made with either and awl or a drill bit
• Use either regular osteotomy fluoroscopic table or fracture table to provide alignment
• Pull out the rod slightly, cut the tip, then drive it into place.

Postoperative management

• Knee immobilizer for 2-4 days
• Range of motion and strengthening - start slowly because of pain and spasm
• Discharge when comfortable - about 4 days after fracture

Problems

• More pain and spasm than with rigid intramedullary fixation
• Shortening and angulation may occur
• Pin protrusion at the level of the knee
• Rod removal is necessary

Results

• Low rates of nonunion and malunion
• Rarely require external support
• Overall satisfactory outcome without need for cast immobilization

IM Nailing of Femoral Fractures in Adolescents: Technique, Results, Complications

Advantages of locked IM nailing

• Controls length, alignment, rotation
  • Especially useful for comminuted fractures
• Allows early mobilization
• Preserves range of motion of adjacent joints
• Has low incidences of nonunion, malunion, infection
• Ideal for comminuted shaft fracture in large teenager near skeletal maturity.

Concerns

• Leg-length discrepancy
• Proximal femoral growth disturbances
• Osteonecrosis of the femoral head

Anatomical considerations

• Vascular anatomy
  • Lateral ascending cervical artery
• Physeal anatomy
  • Proximal femoral physis - metaphyseal growth
  • Trochanteric apophysis - appositional growth

Treatment considerations

• Chronological age
  • Adolescence - begins at 11-12 years of age and extends to skeletal maturity
  • Recommended lower age of IM nailing - ranges from 9-13 years in the literature
• Skeletal age - girls vs boys
• Physical stature
• Length of femur
• Femoral canal diameter - < 8 mm may require extensive reaming for rod insertion
• Fracture location
  • Distal to lesser trochanter
  • At least 5 cm proximal to distal femoral physis
• Fracture pattern - locked IM nail can be used for transverse, oblique, or comminuted
• Concomitant injuries: multiple trauma, head injury, floating knee
• Irreducible fractures
• Open fractures

Results and complications

• Nearly all series report no nonunions, malunions, or infections.
• Prevalence of clinically significant leg length discrepancy ranges from 0 to 6%.
  • In our current series of 58 adolescents, LLD averaged 0.7 cm; 2 had LLD of 2.5 cm and 3.2 overgrowth that could not be by concomitant injuries.
• Risk of overgrowth small in adolescents with < 2 years of growth remaining.
• Osteonecrosis of femoral head most serious potential complication
  • Sporadic cases reported in literature, all with piriformis fossa entry portal.
  • In our series of 58, only 1 with osteonecrosis, also with piriformis portal from 1989; none since switching to tip of trochanter portal

Technique of antegrade IM nail insertion

• Placement of a threaded tip guide wire through the tip of the greater trochanter with confirmation of correct placement on AP and lateral fluoroscopy, to determine the correct entry portal.
• No medial dissection is performed and no awl is used to create the portal.
• A 9-mm reamer is inserted over the threaded-tip guide wire into the subtrochanteric region, the fracture is reduced, and a straight, smooth-tip, standard guide wire is advanced across the fracture.
• The femoral canal is reamed to 1 mm larger than the nail, the nail is inserted and is static locked (screws proximally and distally).
• Use 8, 9, 10-mm nails when possible.

Postoperative management

• Touch-down weight bearing only initially; weight bearing is advanced as fracture heals.
• Nail removed 12 to 18 months after injury if fracture union is solid, because later nail removal may be more difficult .
• Patients should be followed for at least two years after injury and preferably until skeletal maturity.

Pearls and pitfalls

• Use tip of trochanter for entry portal, NOT piriformis fossa
• Dissection limited to tip of greater trochanter - DO NOT extend into posterior capsule or midportion of femoral neck
• Use smallest nail possible
• Proximal end of nail left long (up to 1 cm) to make removal easier

Selected references

Beaty JH: Aseptic necrosis of the femoral head following antegrade nailing of femoral fractures in adolescents. Tech Orthop 1998; 13:96-99.

Beaty JH, Austin SM, Warner WC, Canale ST, Nichols L: Interlocking intramedullary nailing of femoral shaft fractures in adolescents: preliminary results and complications. J Pediatr Orthop 14:178, 1994.

Blaiser RD, Aronson J, Tursky EA: External fixation of pediatric femur fractures. J Pediatr Orthop 17:342, 1997.

Buehler KC, Thompson JD, Sponseller PD, et al: A prospective study of early spica casting outcomes in the treatment of femoral shaft fractures in children. J Pediatr Orthop 15:30, 1995.

Canale ST, Tolo VT: Fractures of the femur in children (Instr Course Lect). J Bone Joint Surg 77-A:294, 1995.

Carey TP, Galpin RD: Flexible intramedullary nail fixation of pediatric femoral fractures. Clin Orthop 332:110, 1996.

Erikkson E, Hovelius L: Ender nailing in fractures of the diaphysis of the femur. J Bone Joint Surg 61-A:1175, 1979.

Galpin RD, Willis RB, Sabano N: Intramedullary nailing of pediatric femoral fractures. J Pediatr Orthop 14:184, 1994.

Gregory P, Pevny T, Teague D: Early complications with external fixation of pediatric femoral shaft fractures. J Orthop Trauma 10:191, 1996.

Heinrich SD, et al: The operative stabilization of pediatric diaphyseal femur fractures with flexible intra- medullary nails: a prospective analysis. J Pediatr Orthop 14:501, 1994.

Hughes BF, Sponseller PD, Thompson JD: Pediatric femur fractures: effects of spica cast treatment on family and community. J Pediatr Orthop 15:461, 1995.

Ligier JN, Metaizeau JP, Prevot J, Lascombe P: Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg 70-B:74, 1988.

Martinez AG, Carroll NC, Sarwark JF, et al: Femoral shaft fractures in children treated with early spcia cast. J Pediatr Orthop 11:712, 1992.

McGraw JJ, Gregory SK: Ender nails: an alternative for intramedullary fixation of femoral shaft fracture in children and adolescents. South Med J 90:694, 1997.

Price CT, Levengood GA, Zink WP: The treatment of pediatric fractures with dynamic axial external fixation. Tech Orthop 4:74, 1989.

Reeves RB, Ballard RI, Hughes JL: Internal fixation versus traction and casting of adolescent femoral shaft fractures. J Pediatr Orthop 10:592, 1990.

Thometz JG, Lamdan R: Osteonecrosis of the femoral head after intramedullary nailing of a fracture of the femoral shaft in an adolescent: a case report. J Bone Joint Surg 77-A:1423, 1995.

Timmerman LA, Rab GT: Intramedullary nailing of femoral shaft fractures in adolescents. J Orthop Trauma 1993; 7:331-337.

Ward WT, Levy J, Kaye A: Compression plating for child and adolescent femur fractures. J Pediatr Orthop 12:626, 1992.