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Femoral shaft fractures in children
Injury, Int. J. Care Injured (2005) 36, S-A86—S-A93
Femoral shaft fractures Basic concepts relevant in to children the design and development of the Point Contact Fixator (PC-Fix) James B. Hunter Stephan M. Perren and Orthopaedic Surgeon, Queen’s Medical Centre, Nottingham, UK Consultant Trauma and Paediatric Joy S. Buchanan AO/ASIF Research Institute, Clavadelerstrasse, 7270 Davos, Switzerland AO/ASIF KEYWORDS: Research Institute, Clavadelerstrasse, Summary1 Femoral 7270 shaft Davos, fractures Switzerland are the commonest diaphyseal fractures of Adolescent; bone nails; child, preschool; femoral fractures; KEYWORDS: fracture fixation; One sillymethods; fountain; internal external methods; Progressive dwarves; human; Umpteenpostoperamats; tive Five complications; silly trailers; prospective studies; titanium treatment outcome.
childhood after those of the radial and ulnar shaft and the tibial shaft. Common mechanisms include falls, particularly from playground equipment, motor vehicle accidents and sporting injuries. Unlike in adults, femoral shaft fractures are Summary1 isolated bla bla injuries bla bla One aardvark In marries thethey pawnbroker, eventothough five commonly in children. infants, may be due non-accibourgeois catsTreatment tickled umpteen Macintoshes, but two obese elephants drunkenly dental injury. of femoral shaft fractures varies with the age and size of towed umpteen almost irascible Two bureaux easilymodalities telephoned Paul, children, associated injuries andsheep. local practice. Current used foreven the though theofwart hogs shaft gossips, but one elephant tastes partly putrid wart hogs, treatment femoral fractures include various forms of traction, immedibecause umpteen botulisms kisses Mark, although the subways bought and one ate and late spicapurple casting, elastic nailing, external fixation, plate fixation, extremely angst-ridden lampstand, even though five and obese televisions All perused conventional intramedullary nailing for older children adolescents. these subways, five progressive auctioned off the bureau, although trailforms of then treatment have beenmats reported as being successful in cohorttwo studies. ers grew but irascible Jabberwockies five controversies speedy fountains, yet one Very few up, comparative studies exist. The untangles main current are the age catwhich ran away, then the trailer very appropriate cleverly kisses two irascible bureaux.manageat elastic nailing becomes instead of conservative ment, and secondly, the treatment of the older, heavier child for whom elastic nails may not be appropriate. Familiarity with several methods of femoral shaft stabilisation is appropriate. The major determinant in the choice of treatment is cultural.
Principles of treatment The principles of treatment of the child’s femoral shaft fracture were given in a classic paper by Dameron and Thompson in 1959 [6]. They stated: 1. The simplest satisfactory treatment was the best treatment. 2. The initial treatment should be definitive whenever possible. 3. Anatomic reduction was not required for perfect function. 4. Alignment must be restored, especially rotational alignment. 5. The more growth that remained, the more remodelling was available. 6. The limb should be immobilised in a splint until definitive treatment had been instituted.
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Abstracts in German, German, French, French,Italian, Italian,Spanish, Spanish,Japanese, Japanese and Russian are printed at the end of this supplement.
0020–1383/$ — see front matter ß 2004 Published by Elsevier Ltd. doi:10.1016/j.injury.2004.12.018
These principles still hold, although many would argue that routine use of more invasive treatments is acceptable if this results in the return of the child to its normal environment in a timely fashion, without an excess of complications.
Treatment at different ages A. Infants 0–18 months old In this age group the mechanism of injury must be diligently sought, as non-accidental injury (NAI) and child abuse can present with an isolated femoral fracture at this age. An infant that is completely non-ambulatory, that is to say, unable to crawl or roll, is more likely than not to have sustained an NAI [2]. The fracture pattern is not particularly helpful in deciding whether the injury is non-accidental [21]. Associated injuries, such as head injuries, digital bruising patterns, etc, need to be sought.
Femoral shaft fractures in children
During the first year of life, as an infant becomes more mobile, the likelihood of accidental as opposed to non-accidental injury increases. In an infant of walking age, an isolated femoral fracture is more likely to be accidental than non-accidental [22]. The treatment of an infant’s femoral shaft fracture rarely involves operative stabilisation. Most of the fractures in this age group can be treated either by traction methods or spica casting or by a combination of the two. If the child is under 18 months, the most common traction modality is Bryant’s or gallows traction, where the child is supine with the hips flexed 90°, the legs being pulled directly upwards. This form of traction, which sounds extremely simple, needs to be applied with care to avoid complications. We do not use this form of traction on children older than 18 months and generally reserve it for children under one year. Heavier infants should not be immobilized with gallows traction as they require too much weight to lift the bottom from the bed. The weight applied should be sufficient to allow the surgeon to slip their hand underneath the nappy, but no more. Gallows traction has been associated with vascular problems, including severe compartment syndrome and Volkmann’s ischaemic contracture [19]. This is due to the elevated position of the legs and the straightness of the knees, together with tightness of the compression bandaging. Vascular problems can be avoided by applying the traction carefully, allowing some knee flexion and correct tension of the bandaging. In our unit, the skin of the legs is examined each day, initially with careful reapplication of the bandaging, but not the skin traction itself. The older infant 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. Because of potential NAI, it is useful to commence the treatment of all infants under 18 months with a period of traction. This allows careful examination of the history, discussion with social services and full assessment of the needs of the child in uncontroversial circumstances. Thereafter, the choice of treatment lies between continuing the traction and spica casting. In many general hospitals worldwide, it is easier to care for an infant under two years of age on the ward than to obtain a paediatric anaesthetist. Early spica casting requires an anaesthetic, although late casting, when the fracture is sticky, can frequently be done without [10]. In the infant age group, where the 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. Management of a child in a spica cast is
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most easy at this age and parents may choose to take their infant home in a spica and a buggy. Once a hip spica has been applied, generally in a sitting-type position with hip and knee flexion, it should be left in place for at least three weeks to avoid the need for re-application. 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.
B. Treatment of small children and toddlers 18 months to 4 years Conservative methods are the mainstay of treatment in this age group. The aetiology of femoral shaft fractures in these children is nearly always a straightforward accident, either a fall from playground equipment or a simple fall. Gallows traction is inappropriate for these children and they can be managed on 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 [8]. A traction pin is not required in this age group. Successful results have been described with all forms of traction, although the use of a Thomas or Liston splint can be associated with skin problems [25]. 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. If traction methods are used, then a useful rule of thumb is that one pound of weight (0.5 kg) should be used for every year of age and one week of traction is required for every year of age; thus a three-year-old’s fracture would be immobilized for three weeks using three pounds (1.5 kg) of traction. Hamilton-Russell traction notionally produces some mechanical advantage, but this is offset by friction in all hospital pulley systems. Children of this age can normally be managed in a hip spica, applied early or late. Fractures that have shortened considerably at initial presentation should be managed with traction initially and late spica casting. Immediate spica casting became popular in the 1970s, mainly under pressure to reduce costs in the USA health care system. Length and alignment of the femur are maintained by flexing both the hip and the knee and moulding the cast in these places. A sitting position, not dissimilar to that achieved by 90/90 traction, controls rotation and allows the child to be easily transported. Staheli introduced rules to guide surgeons in the use of spica casting, stating (1) that the parents must be reliable, (2) that the fracture must be uncomplicated, (3) that the up-
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per age limit for such treatment was eight, (4) that the child needed to be in satisfactory condition for a general anaesthetic and (5) that initial traction should be used if there was any doubt about the stability of the fracture [24]. Fractures treated in an early spica cast must be monitored for angulation and in particular, for shortening. Generally speaking, shortening beyond 15 mm in the early stages of treatment is unacceptable and should lead to a resumption of traction methods. The child of this age has considerable capacity for remodelling –15° of varus/valgus angulation and 25°of flexion or extension can be accepted [28]. Care must be taken not to overly mould the spica cast; compartment syndrome has been described as a complication of early spica application [16].
C. Children aged 4–12 years Children in this age group can be treated with a variety of methods.
1. Traction methods Traction methods may still be applicable. Simple skin traction, however, rarely lasts more than five or six weeks because of skin problems. Therefore, if traction methods are to be used definitively, a traction pin may be required to apply the correct amount of weight. For younger children, there is no advantage to skeletal over skin traction [8]. A child requires a general anaesthetic for a traction pin to be placed and therefore consideration should be given to operative stabilization instead. Traction pins can be placed in the distal femur or in the tibia, but if the latter site is used, care must be taken to avoid the physis, where it extends distally in the region of the tibial tuberosity. Severe growth disturbances from tibial pin placement have been described. As the scars from elastic stable intramedullary nailing (ESIN) are only marginally larger and in a similar position to those from distal femoral traction, the definitive nature of ESIN makes it an excellent choice and skeletal traction has not been used in our unit to manage a femoral fracture for over a decade.
2. Hip spica Successful use of hip spica treatment in this age group, up to the age of eight, has been reported. However, it seems likely that only an insurance company would wish to treat a mobile 6-year-old
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in a hip spica. The disadvantages in terms of skin care, hygiene, education, and social isolation seem insurmountable. Very few schools can accept a child in a hip spica and thus, in a 6 to 8-year-old, this treatment modality will result in a whole term off school. For these reasons, we do not use hip spica treatment in the older child (over four years), unless parents specifically request it.
3. Elastic nailing This is the major method for stabilizing femoral shaft fractures in this age group in Europe. The history and development of this technique is described elsewhere in this supplement. Technique The operation can be performed either on a fracture table or, in smaller children, on an ordinary radiolucent table, but with either a post or a sheet in the groin to allow counter-traction. Fractures of the middle and proximal thirds of the shaft are nailed using two C-shaped nails placed distal to proximal. The start point is 2 cm proximal to the distal femoral physis in the supracondylar area. The start point is made with an awl or a drill and pre-shaped nails are inserted with their maximum bend placed at the level of the fracture site. It is important that each nail has the same diameter and that they are identically pro-curved to create a balanced construct. Both nails are inserted to the level of the fracture and then under image intensification both are placed across the fracture site with light hammering. It is important that the nails are not wound round each other to create a corkscrew, as this lessens the mechanical effect. The nails are advanced towards the proximal metaphysis and should reach a level equivalent to the top of the lesser trochanter to gain a good hold. Just prior to reaching this level, they should be cut off and then impacted, leaving approximately 1 cm of nail protruding to facilitate retrieval. The nail should not be bent outwards as this can lead to irritation of the fascia lata and indeed the skin, which was a frequently described problem in earlier series. Fractures of the distal third should be nailed using a downgoing technique. The start points are on the lateral surface of the femur, just below the lesser trochanter. Separate start points are used for the two nails, with the second start point being a little distal and anterior to the first. In order to achieve divergent nails at the fracture site, one nail is Cshaped, and the other is S-shaped. The S-shaped nail can be created either by pre-bending the nail or by starting with a C-shaped nail and then bending
Femoral shaft fractures in children
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it in the opposite direction, after it has been turned through 180°. Postoperatively, mobilization is started immediately. Initially, weight-bearing is restricted, but 2–3 weeks later, weight-bearing can be as pain allows and many children achieve full weight-bearing 2–3 weeks after insertion of elastic nails. More unstable fracture patterns obviously need a more cautious approach and for fractures with a tendency to angulate despite correct contouring of the nails, a period of traction or a brace may be necessary. This, however, is rare. The system relies on a certain amount of integrity of the soft tissues around the femur, so it should be borne in mind that severe open fractures with soft-tissue loss will be less stable with elastic nailing than with other methods. The fractures heal with abundant callus, as if they had been treated conservatively (Fig. 1). Leg length discrepancy mostly occurs if the fracture
has been lengthened intraoperatively and it can be prevented by impaction of the fracture at the end of the operation. Rotational malalignment needs to be checked before final impaction of the nails into the proximal metaphysis, which is most easily done by comparison with the other leg. Retrieval of the metalwork is not compulsory, but is generally performed. The fracture should be fully consolidated before metalwork retrieval, normally at six months. The advantages of elastic nailing are abundant. The technique is minimally invasive and healing occurs in an extremely natural way with a mass of callus. Retrieval of the hardware is easy, provided the ends have been left long enough, although an anaesthetic is required. The re-fracture rate is negligible, as is the infection rate. Early return to school and social activities is possible [17]. The complications of elastic nailing mostly concern the nail left protruding at the entry point. For many years, outward bending of the nail to facilitate retrieval was recommended, but this can cause anything from irritation to skin necrosis and infection and therefore should be avoided (Fig. 2). Most of the complications described in the literature are in fact features of inexact technique and experiences from the learning curve and can be eliminated [9, 18].
Fig.1: Femur treated with ESIN. The nails are left lying on the bone not bent outwards, and the fracture heals with abundant callus.
Fig. 2: Skin penetration by nail ends contoured outwards to facilitate retrieval.
Fig. 3: External fixation should not be too rigid and should be dynamized early.
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4. External fixation
5. Plate fixation
The use of external fixation of pediatric femoral shaft fractures has been described since the late 70s and early 80s with considerable enthusiasm and in many publications between 1989 and the mid-1990s. The indication for external fixation in children was initially the same as in adults; for managing open fractures and fractures associated with burns or other severe soft-tissue injuries [1]. Although early experiences were associated with difficulties and complications, such as slow union and re-fracture, they were attributed to the severity of the injuries. The use of external fixation rapidly spread to the treatment of closed and simple femoral shaft fractures (Fig. 3). The advantages of the technique are the ease of application and the fact that, in the older child at least, removal can be performed without general anaesthesia. The disadvantages are the frequently reported increased re-fracture rate and the relatively slow time to union [23]. The staff at Texas Scottish Rite recommend that external fixators be left on for 10–12 weeks until union is solid to prevent excessive re-fracture [13]. Two major European studies have shown a median time to fixator removal of eight weeks or more [12, 14]. The problems with pin site infection and the rather unattractive pin site scars are well documented from both trauma and limb lengthening experience. The fact that the time to union is slow does not matter if the child is allowed to function normally. Certainly, an external fixator allows early weight-bearing at least as early as elastic nailing. The external fixator does, however, exclude a child from certain activities. The defensive litigious societies of the West have unfortunately reduced the range of activities for children with external fixators. In the UK, many schools will now not accept a child wearing an external fixator and for these social and cultural reasons, this method has become less popular. The re-fracture rate cannot be ignored. It is notable that fractures treated by external fixation tend to heal with minimal callus, suggesting that most external fixators applied to children are too rigid. It is well recognized that direct bone healing occurs far more slowly than bone healing with callus. In general, femoral fractures in children require only four pins with a maximum of six. Formal dynamisation appears to have made little difference to healing rates and this may be because late dynamisation of a frame that was too rigid initially will not allow bone healing with callus, whereas an initially less rigid frame will [7]. External fixation of femoral fractures in this age group most certainly has its place in polytrauma and associated soft-tissue injuries and surgeons treating paediatric trauma need to be familiar with its use.
There are many reports in the literature of cohorts of children’s femoral fractures treated successfully with plate fixation [29]. The advantages of plate fixation are that it can be done without fluoroscopy and that it offers excellent control of proximal shaft fractures, which can be difficult to manage with both elastic nailing and external fixation. The disadvantages are that for conventional plating substantial exposure is required, with at least some muscle stripping and devascularisation of bone and for many children a lengthy scar is a considerable issue (Fig. 4a, b). Plate removal would require another extensive operation and the residual screw holes are a considerable risk for re-fracture, as they are in the child’s forearm. 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 [15]. Recently, there has been a considerable trend in both adult and children’s practice towards minimally invasive plate osteosynthesis. This procedure has the advantages of reducing the scar and leaving the softtissue envelope more intact, but risks inexact fixation and the possibility of leg lengthening. Leg length discrepancy has been variably reported after plate fixation [5]. 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. The indication for plating in this age group for fractures that are amenable to elastic nailing or external fixation is probably extremely small and this is reflected in the small numbers reported in the literature.
Fig. 4a, b: Plate fixation of femur is effective but can leave a significant scar.
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Comparative studies in the literature
Older children/adolescents
A Medline search conducted for the purposes of constructing this article identified 1900 papers. Restricting this search using the keywords “comparison” or “cohort” produced 51 articles of which 16 were articles in which two or more treatment modalities were compared. Wright performed a similar exercise in his article published in 2000 [31]. His major conclusion was that the literature was of extremely poor quality. He also concluded that early application of a hip spica had lower costs and malunion rates than treatment on traction. The poor quality of the literature has been partially rectified by his own randomized prospective control trial (RCT) comparing early application of hip spica and external fixation for the treatment of paediatric femoral fractures, which was presented to the Pediatric Orthopedic Society of North America in 2003 [30]. The primary outcome of this study was malunion at two years, which was defined as greater than 2 cm of limb length discrepancy, greater than 15° of angulation in the sagittal plane or 10° in the coronal plane. The rate of malunion in the hip spica group was 45% compared to 16% in the external fixator group. There was no difference in functional outcome, parental or child satisfaction. The criteria for malunion may seem a little stringent, however, it should be recognized that these criteria were applied at two years of follow-up after the majority of remodelling would have occurred. In his study there was only one re-fracture in the external fixator group of 45 patients. This study shows the advantages of an RCT, even when the assumption is made that there is little clinical outcome difference between the two groups. The Cincinnati group has examined its cohorts treated with traction, followed by spica casting, compared with ESIN and found no difference in clinical and functional criteria. They found that elastic nailing was less costly than traction followed by spica casting because of the prolonged stay for the latter and that parents were more satisfied with elastic nailing [4]. Although it is tempting to believe that a trial of external fixation versus elastic nailing would be the next logical step, it should be recognized that both produce a high percentage of very satisfactory results clinically, functionally and in terms of satisfaction and that therefore it would be very difficult to conduct a sufficiently large trial to produce a meaningful outcome. Wright’s earlier work had suggested that hip spica treatment was consistently cheaper than external fixation, even when considering the range of complications, however, given the number of secondary surgeries in the hip spica group in his RCT, it is likely that these relative costs will be reversed.
Conservative methods As a child gets older, approaching adulthood and skeletal maturity, conservative methods become increasingly inappropriate for managing femoral shaft fractures. Management in a hip spica is impossible in the older child or adolescent. Traction methods require the placement of skeletal traction pins and the tendency is towards malunion, shortening and prolonged treatment times. It is more than 20 years since the disadvantages of traction and the advantages of intramedullary nailing of adolescent femoral fractures were first pointed out.
Elastic nailing Elastic nailing of the adolescent femoral shaft fracture can be performed using the same techniques described earlier. Currently, the largest available diameter of elastic nail is 4 mm. Two 4 mm nails are the appropriate implants for femoral shafts with an isthmus diameter of 10–12 mm. The intramedullary canals of adolescents are never larger than this, so larger diameter elastic nails would not be appropriate. The concern about elastic nails is whether they are strong enough to stabilise the fractures of heavier children. There is no definitive advice available in the literature, but there is a feeling among surgeons that 50 or 60 kg is the upper limit of child weight in which elastic nailing of the femoral shaft is appropriate. I have personally used elastic nails to stabilize a femoral shaft fracture in a boy who weighed 61 kg. There is no doubt that the method can be used with caution in this age and size of child. A brief period of bed rest or use of a femoral brace after the operation may be required.
Plate osteosynthesis Plates can be applied to adolescent femoral shaft fractures using both conventional and minimally invasive techniques. Plate configurations that achieve relative stability are most appropriate for adolescents and good results have been reported.
Locked intramedullary nailing The use of conventional adult pattern femoral nails for shaft fractures in adolescents is the most controversial area in this subject. The effectiveness of intramedullary nailing for the treatment of
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the adolescent femoral shaft is beyond doubt [32]. Several relatively large series have been published demonstrating the success of the implant in achieving length, alignment, and union [11]. The problem is the incidence of avascular necrosis of the femoral head that has been associated with the use of intramedullary nailing in children and adolescents [3, 26]. 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 considerably at risk from a nail that uses the piriformis fossa start point, or indeed one that starts on the medial part of the greater trochanter and whose insertion involves reaming out the medial wall of the greater trochanter. There is no nail currently on the market that can guarantee to avoid both of these places, although a nail has been presented that is inserted through the lateral surface of the trochanter, with promising early results [20]. Nailing through the trochanter tip is said to be safe [27]. The incidence of avascular necrosis after intramedullary nailing in adolescence is unknown. Large series tend to report only a single case, suggesting an incidence of 1–2%, but with a very wide confidence interval. The Pediatric Orthopedic Society of North America (POSNA) surveyed its members and identified more than 30 cases, but with an unknown denominator. This question is therefore not going to be solved by scientific study and is a philosophical point. Avascular necrosis of the femoral head is a devastating and untreatable condition. Some take the view that it is unreasonable to expose the older child to this complication when there are a variety of satisfactory alternative treatment modalities available for the fracture. Avascular necrosis of the femoral head has never been reported with ascending elastic nailing or plating of the femur. The matter was debated in the Journal of Paediatric Orthopaedics in late 2002. Green alluded in that article to his personal series of 175 intramedullary nailings performed with careful technique, including initial reaming over a guide wire. There were no cases of avascular necrosis. Letts abandoned his series after a case of avascular necrosis, even though over 50 children had been successfully treated without complication. My personal preference is to avoid 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 fixa-
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tion or plating. There are particular problems in the United States of America where adolescent weights of over 120 kg are now routinely being seen. In these children, the biomechanical advantages of a nail are clear. If an intramedullary nail is to be used prior to physeal closure, then informed consent would need to refer to a 1–2% incidence of avascular necrosis and the very serious nature of the complication.
Conclusions Multiple methods are available for treating children’s femoral shaft fractures. Surgeons need to be familiar with them all. The major determinants in choosing a particular method are local circumstances, costs, and culture. There is emerging evidence that surgical stabilisation produces less malunion and greater parent satisfaction than treatment in a spica. Locked intramedullary nailing is associated with avascular necrosis of the femoral head, a rare but devastating complication.
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11. Galpin RD, Willis RB, Sabano N (1994) Intramedullary nailing of pediatric femoral fractures. J Pediatr Orthop; 14(2):184– 189. 12. Hedin H, Hjorth K, Rehnberg L, et al (2003) External fixation of displaced femoral shaft fractures in children: a consecutive study of 98 fractures. J Orthop Trauma; 17(4):250–256. 13. Herring J (2002) Tachdjian‘s Pediatric Orthopaedics. 3rd ed. Philadelphia London New York St Louis Sydney Toronto, WB Saunders. 14. Hull JB, Sanderson PL, Rickman M, et al (1997) External fixation of children‘s fractures: use of the Orthofix Dynamic Axial Fixator. J Pediatr Orthop B; 6(3):203–206. 15. Kregor PJ, Song KM, Routt ML Jr, et al (1993) Plate fixation of femoral shaft fractures in multiply injured children. J Bone Joint Surg Am; 75(12):1774–1780. 16. Large TM, Frick SL (2003) Compartment syndrome of the leg after treatment of a femoral fracture with an early sitting spica cast. A report of two cases. J Bone Joint Surg Am; 85A(11):2207–2210. 17. Ligier JN, Metaizeau JP, Prevot J, et al (1988) Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br; 70(1):74–77. 18. Luhmann SJ, Schootman M, Schoenecker PL, et al (2003) Complications of titanium elastic nails for pediatric femoral shaft fractures. J Pediatr Orthop; 23(4):443–447. 19. Mubarak SJ, Carroll NC (1979) Volkmann‘s contracture in children: aetiology and prevention. J Bone Joint Surg Br; 61-B(3):285–293. 20. Phillips J (2001) The management of paediatric femur fractures with a flexible interlocked intramedullary nail: preliminary results of the use of a new device. EPOS; Montpellier. 21. Scherl SA, Miller L, Lively N, et al (2000) Accidental and nonaccidental femur fractures in children. Clin Orthop; 96–105. 22. Schwend RM, Werth C, Johnston A (2000) Femur shaft fractures in toddlers and young children: rarely from child abuse. J Pediatr Orthop; 20(4):475–481. 23. Skaggs DL, Leet AI, Money MD, et al (1999) Secondary fractures associated with external fixation in pediatric femur fractures. J Pediatr Orthop; 19(5):582–586. 24. Staheli LT, Sheridan GW (1977) Early spica cast management of femoral shaft fractures in young children. A technique utilizing bilateral fixed skin traction. Clin Orthop; 162–166. 25. Sutcliffe JR, Wilson-Storey D, Mackinlay GA (1995) Children‘s femoral fractures: the Edinburgh experience. J R Coll Surg Edinb; 40(6):411–415. 26. Thometz JG, Lamdan R (1995) 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 Am; 77(9):1423–1426. 27. Townsend DR, Hoffinger S (2000) Intramedullary nailing of femoral shaft fractures in children via the trochanter tip. Clin Orthop; 113–118. 28. Wallace ME, Hoffman EB (1992) Remodelling of angular deformity after femoral shaft fractures in children. J Bone Joint Surg Br; 74(5):765–769. 29. Ward WT, Levy J, Kaye A (1992) Compression plating for child and adolescent femur fractures. J Pediatr Orthop; 12(5):626–632.
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30. Wright J, Wang E, Coyte P, et al (2003) A randomised trial comparing early hip spica application and external fixation for the treatment of pediatric femoral fractures. POSNA Annual Meeting; Amelia Island FL. 31. Wright JG (2000) The treatment of femoral shaft fractures in children: a systematic overview and critical appraisal of the literature. Can J Surg; 43(3):180–189. 32. Ziv I, Blackburn N, Rang M (1984) Femoral intramedullary nailing in the growing child. J Trauma; 24(5):432–434.
Correspondence address: Dr. James B. Hunter BA FRCSEd (Orth) Consultant Trauma and Paediatric Orthopaedic Surgeon Queen’s Medical Centre Nottingham, NG7 2UH, GB email: [email protected]
Femoral shaft fractures Basic concepts relevant in to children the design and development of the Point Contact Fixator (PC-Fix) James B. Hunter Stephan M. Perren and Orthopaedic Surgeon, Queen’s Medical Centre, Nottingham, UK Consultant Trauma and Paediatric Joy S. Buchanan AO/ASIF Research Institute, Clavadelerstrasse, 7270 Davos, Switzerland AO/ASIF KEYWORDS: Research Institute, Clavadelerstrasse, Summary1 Femoral 7270 shaft Davos, fractures Switzerland are the commonest diaphyseal fractures of Adolescent; bone nails; child, preschool; femoral fractures; KEYWORDS: fracture fixation; One sillymethods; fountain; internal external methods; Progressive dwarves; human; Umpteenpostoperamats; tive Five complications; silly trailers; prospective studies; titanium treatment outcome.
childhood after those of the radial and ulnar shaft and the tibial shaft. Common mechanisms include falls, particularly from playground equipment, motor vehicle accidents and sporting injuries. Unlike in adults, femoral shaft fractures are Summary1 isolated bla bla injuries bla bla One aardvark In marries thethey pawnbroker, eventothough five commonly in children. infants, may be due non-accibourgeois catsTreatment tickled umpteen Macintoshes, but two obese elephants drunkenly dental injury. of femoral shaft fractures varies with the age and size of towed umpteen almost irascible Two bureaux easilymodalities telephoned Paul, children, associated injuries andsheep. local practice. Current used foreven the though theofwart hogs shaft gossips, but one elephant tastes partly putrid wart hogs, treatment femoral fractures include various forms of traction, immedibecause umpteen botulisms kisses Mark, although the subways bought and one ate and late spicapurple casting, elastic nailing, external fixation, plate fixation, extremely angst-ridden lampstand, even though five and obese televisions All perused conventional intramedullary nailing for older children adolescents. these subways, five progressive auctioned off the bureau, although trailforms of then treatment have beenmats reported as being successful in cohorttwo studies. ers grew but irascible Jabberwockies five controversies speedy fountains, yet one Very few up, comparative studies exist. The untangles main current are the age catwhich ran away, then the trailer very appropriate cleverly kisses two irascible bureaux.manageat elastic nailing becomes instead of conservative ment, and secondly, the treatment of the older, heavier child for whom elastic nails may not be appropriate. Familiarity with several methods of femoral shaft stabilisation is appropriate. The major determinant in the choice of treatment is cultural.
Principles of treatment The principles of treatment of the child’s femoral shaft fracture were given in a classic paper by Dameron and Thompson in 1959 [6]. They stated: 1. The simplest satisfactory treatment was the best treatment. 2. The initial treatment should be definitive whenever possible. 3. Anatomic reduction was not required for perfect function. 4. Alignment must be restored, especially rotational alignment. 5. The more growth that remained, the more remodelling was available. 6. The limb should be immobilised in a splint until definitive treatment had been instituted.
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Abstracts in German, German, French, French,Italian, Italian,Spanish, Spanish,Japanese, Japanese and Russian are printed at the end of this supplement.
0020–1383/$ — see front matter ß 2004 Published by Elsevier Ltd. doi:10.1016/j.injury.2004.12.018
These principles still hold, although many would argue that routine use of more invasive treatments is acceptable if this results in the return of the child to its normal environment in a timely fashion, without an excess of complications.
Treatment at different ages A. Infants 0–18 months old In this age group the mechanism of injury must be diligently sought, as non-accidental injury (NAI) and child abuse can present with an isolated femoral fracture at this age. An infant that is completely non-ambulatory, that is to say, unable to crawl or roll, is more likely than not to have sustained an NAI [2]. The fracture pattern is not particularly helpful in deciding whether the injury is non-accidental [21]. Associated injuries, such as head injuries, digital bruising patterns, etc, need to be sought.
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During the first year of life, as an infant becomes more mobile, the likelihood of accidental as opposed to non-accidental injury increases. In an infant of walking age, an isolated femoral fracture is more likely to be accidental than non-accidental [22]. The treatment of an infant’s femoral shaft fracture rarely involves operative stabilisation. Most of the fractures in this age group can be treated either by traction methods or spica casting or by a combination of the two. If the child is under 18 months, the most common traction modality is Bryant’s or gallows traction, where the child is supine with the hips flexed 90°, the legs being pulled directly upwards. This form of traction, which sounds extremely simple, needs to be applied with care to avoid complications. We do not use this form of traction on children older than 18 months and generally reserve it for children under one year. Heavier infants should not be immobilized with gallows traction as they require too much weight to lift the bottom from the bed. The weight applied should be sufficient to allow the surgeon to slip their hand underneath the nappy, but no more. Gallows traction has been associated with vascular problems, including severe compartment syndrome and Volkmann’s ischaemic contracture [19]. This is due to the elevated position of the legs and the straightness of the knees, together with tightness of the compression bandaging. Vascular problems can be avoided by applying the traction carefully, allowing some knee flexion and correct tension of the bandaging. In our unit, the skin of the legs is examined each day, initially with careful reapplication of the bandaging, but not the skin traction itself. The older infant 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. Because of potential NAI, it is useful to commence the treatment of all infants under 18 months with a period of traction. This allows careful examination of the history, discussion with social services and full assessment of the needs of the child in uncontroversial circumstances. Thereafter, the choice of treatment lies between continuing the traction and spica casting. In many general hospitals worldwide, it is easier to care for an infant under two years of age on the ward than to obtain a paediatric anaesthetist. Early spica casting requires an anaesthetic, although late casting, when the fracture is sticky, can frequently be done without [10]. In the infant age group, where the 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. Management of a child in a spica cast is
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most easy at this age and parents may choose to take their infant home in a spica and a buggy. Once a hip spica has been applied, generally in a sitting-type position with hip and knee flexion, it should be left in place for at least three weeks to avoid the need for re-application. 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.
B. Treatment of small children and toddlers 18 months to 4 years Conservative methods are the mainstay of treatment in this age group. The aetiology of femoral shaft fractures in these children is nearly always a straightforward accident, either a fall from playground equipment or a simple fall. Gallows traction is inappropriate for these children and they can be managed on 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 [8]. A traction pin is not required in this age group. Successful results have been described with all forms of traction, although the use of a Thomas or Liston splint can be associated with skin problems [25]. 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. If traction methods are used, then a useful rule of thumb is that one pound of weight (0.5 kg) should be used for every year of age and one week of traction is required for every year of age; thus a three-year-old’s fracture would be immobilized for three weeks using three pounds (1.5 kg) of traction. Hamilton-Russell traction notionally produces some mechanical advantage, but this is offset by friction in all hospital pulley systems. Children of this age can normally be managed in a hip spica, applied early or late. Fractures that have shortened considerably at initial presentation should be managed with traction initially and late spica casting. Immediate spica casting became popular in the 1970s, mainly under pressure to reduce costs in the USA health care system. Length and alignment of the femur are maintained by flexing both the hip and the knee and moulding the cast in these places. A sitting position, not dissimilar to that achieved by 90/90 traction, controls rotation and allows the child to be easily transported. Staheli introduced rules to guide surgeons in the use of spica casting, stating (1) that the parents must be reliable, (2) that the fracture must be uncomplicated, (3) that the up-
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per age limit for such treatment was eight, (4) that the child needed to be in satisfactory condition for a general anaesthetic and (5) that initial traction should be used if there was any doubt about the stability of the fracture [24]. Fractures treated in an early spica cast must be monitored for angulation and in particular, for shortening. Generally speaking, shortening beyond 15 mm in the early stages of treatment is unacceptable and should lead to a resumption of traction methods. The child of this age has considerable capacity for remodelling –15° of varus/valgus angulation and 25°of flexion or extension can be accepted [28]. Care must be taken not to overly mould the spica cast; compartment syndrome has been described as a complication of early spica application [16].
C. Children aged 4–12 years Children in this age group can be treated with a variety of methods.
1. Traction methods Traction methods may still be applicable. Simple skin traction, however, rarely lasts more than five or six weeks because of skin problems. Therefore, if traction methods are to be used definitively, a traction pin may be required to apply the correct amount of weight. For younger children, there is no advantage to skeletal over skin traction [8]. A child requires a general anaesthetic for a traction pin to be placed and therefore consideration should be given to operative stabilization instead. Traction pins can be placed in the distal femur or in the tibia, but if the latter site is used, care must be taken to avoid the physis, where it extends distally in the region of the tibial tuberosity. Severe growth disturbances from tibial pin placement have been described. As the scars from elastic stable intramedullary nailing (ESIN) are only marginally larger and in a similar position to those from distal femoral traction, the definitive nature of ESIN makes it an excellent choice and skeletal traction has not been used in our unit to manage a femoral fracture for over a decade.
2. Hip spica Successful use of hip spica treatment in this age group, up to the age of eight, has been reported. However, it seems likely that only an insurance company would wish to treat a mobile 6-year-old
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in a hip spica. The disadvantages in terms of skin care, hygiene, education, and social isolation seem insurmountable. Very few schools can accept a child in a hip spica and thus, in a 6 to 8-year-old, this treatment modality will result in a whole term off school. For these reasons, we do not use hip spica treatment in the older child (over four years), unless parents specifically request it.
3. Elastic nailing This is the major method for stabilizing femoral shaft fractures in this age group in Europe. The history and development of this technique is described elsewhere in this supplement. Technique The operation can be performed either on a fracture table or, in smaller children, on an ordinary radiolucent table, but with either a post or a sheet in the groin to allow counter-traction. Fractures of the middle and proximal thirds of the shaft are nailed using two C-shaped nails placed distal to proximal. The start point is 2 cm proximal to the distal femoral physis in the supracondylar area. The start point is made with an awl or a drill and pre-shaped nails are inserted with their maximum bend placed at the level of the fracture site. It is important that each nail has the same diameter and that they are identically pro-curved to create a balanced construct. Both nails are inserted to the level of the fracture and then under image intensification both are placed across the fracture site with light hammering. It is important that the nails are not wound round each other to create a corkscrew, as this lessens the mechanical effect. The nails are advanced towards the proximal metaphysis and should reach a level equivalent to the top of the lesser trochanter to gain a good hold. Just prior to reaching this level, they should be cut off and then impacted, leaving approximately 1 cm of nail protruding to facilitate retrieval. The nail should not be bent outwards as this can lead to irritation of the fascia lata and indeed the skin, which was a frequently described problem in earlier series. Fractures of the distal third should be nailed using a downgoing technique. The start points are on the lateral surface of the femur, just below the lesser trochanter. Separate start points are used for the two nails, with the second start point being a little distal and anterior to the first. In order to achieve divergent nails at the fracture site, one nail is Cshaped, and the other is S-shaped. The S-shaped nail can be created either by pre-bending the nail or by starting with a C-shaped nail and then bending
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it in the opposite direction, after it has been turned through 180°. Postoperatively, mobilization is started immediately. Initially, weight-bearing is restricted, but 2–3 weeks later, weight-bearing can be as pain allows and many children achieve full weight-bearing 2–3 weeks after insertion of elastic nails. More unstable fracture patterns obviously need a more cautious approach and for fractures with a tendency to angulate despite correct contouring of the nails, a period of traction or a brace may be necessary. This, however, is rare. The system relies on a certain amount of integrity of the soft tissues around the femur, so it should be borne in mind that severe open fractures with soft-tissue loss will be less stable with elastic nailing than with other methods. The fractures heal with abundant callus, as if they had been treated conservatively (Fig. 1). Leg length discrepancy mostly occurs if the fracture
has been lengthened intraoperatively and it can be prevented by impaction of the fracture at the end of the operation. Rotational malalignment needs to be checked before final impaction of the nails into the proximal metaphysis, which is most easily done by comparison with the other leg. Retrieval of the metalwork is not compulsory, but is generally performed. The fracture should be fully consolidated before metalwork retrieval, normally at six months. The advantages of elastic nailing are abundant. The technique is minimally invasive and healing occurs in an extremely natural way with a mass of callus. Retrieval of the hardware is easy, provided the ends have been left long enough, although an anaesthetic is required. The re-fracture rate is negligible, as is the infection rate. Early return to school and social activities is possible [17]. The complications of elastic nailing mostly concern the nail left protruding at the entry point. For many years, outward bending of the nail to facilitate retrieval was recommended, but this can cause anything from irritation to skin necrosis and infection and therefore should be avoided (Fig. 2). Most of the complications described in the literature are in fact features of inexact technique and experiences from the learning curve and can be eliminated [9, 18].
Fig.1: Femur treated with ESIN. The nails are left lying on the bone not bent outwards, and the fracture heals with abundant callus.
Fig. 2: Skin penetration by nail ends contoured outwards to facilitate retrieval.
Fig. 3: External fixation should not be too rigid and should be dynamized early.
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4. External fixation
5. Plate fixation
The use of external fixation of pediatric femoral shaft fractures has been described since the late 70s and early 80s with considerable enthusiasm and in many publications between 1989 and the mid-1990s. The indication for external fixation in children was initially the same as in adults; for managing open fractures and fractures associated with burns or other severe soft-tissue injuries [1]. Although early experiences were associated with difficulties and complications, such as slow union and re-fracture, they were attributed to the severity of the injuries. The use of external fixation rapidly spread to the treatment of closed and simple femoral shaft fractures (Fig. 3). The advantages of the technique are the ease of application and the fact that, in the older child at least, removal can be performed without general anaesthesia. The disadvantages are the frequently reported increased re-fracture rate and the relatively slow time to union [23]. The staff at Texas Scottish Rite recommend that external fixators be left on for 10–12 weeks until union is solid to prevent excessive re-fracture [13]. Two major European studies have shown a median time to fixator removal of eight weeks or more [12, 14]. The problems with pin site infection and the rather unattractive pin site scars are well documented from both trauma and limb lengthening experience. The fact that the time to union is slow does not matter if the child is allowed to function normally. Certainly, an external fixator allows early weight-bearing at least as early as elastic nailing. The external fixator does, however, exclude a child from certain activities. The defensive litigious societies of the West have unfortunately reduced the range of activities for children with external fixators. In the UK, many schools will now not accept a child wearing an external fixator and for these social and cultural reasons, this method has become less popular. The re-fracture rate cannot be ignored. It is notable that fractures treated by external fixation tend to heal with minimal callus, suggesting that most external fixators applied to children are too rigid. It is well recognized that direct bone healing occurs far more slowly than bone healing with callus. In general, femoral fractures in children require only four pins with a maximum of six. Formal dynamisation appears to have made little difference to healing rates and this may be because late dynamisation of a frame that was too rigid initially will not allow bone healing with callus, whereas an initially less rigid frame will [7]. External fixation of femoral fractures in this age group most certainly has its place in polytrauma and associated soft-tissue injuries and surgeons treating paediatric trauma need to be familiar with its use.
There are many reports in the literature of cohorts of children’s femoral fractures treated successfully with plate fixation [29]. The advantages of plate fixation are that it can be done without fluoroscopy and that it offers excellent control of proximal shaft fractures, which can be difficult to manage with both elastic nailing and external fixation. The disadvantages are that for conventional plating substantial exposure is required, with at least some muscle stripping and devascularisation of bone and for many children a lengthy scar is a considerable issue (Fig. 4a, b). Plate removal would require another extensive operation and the residual screw holes are a considerable risk for re-fracture, as they are in the child’s forearm. 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 [15]. Recently, there has been a considerable trend in both adult and children’s practice towards minimally invasive plate osteosynthesis. This procedure has the advantages of reducing the scar and leaving the softtissue envelope more intact, but risks inexact fixation and the possibility of leg lengthening. Leg length discrepancy has been variably reported after plate fixation [5]. 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. The indication for plating in this age group for fractures that are amenable to elastic nailing or external fixation is probably extremely small and this is reflected in the small numbers reported in the literature.
Fig. 4a, b: Plate fixation of femur is effective but can leave a significant scar.
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Comparative studies in the literature
Older children/adolescents
A Medline search conducted for the purposes of constructing this article identified 1900 papers. Restricting this search using the keywords “comparison” or “cohort” produced 51 articles of which 16 were articles in which two or more treatment modalities were compared. Wright performed a similar exercise in his article published in 2000 [31]. His major conclusion was that the literature was of extremely poor quality. He also concluded that early application of a hip spica had lower costs and malunion rates than treatment on traction. The poor quality of the literature has been partially rectified by his own randomized prospective control trial (RCT) comparing early application of hip spica and external fixation for the treatment of paediatric femoral fractures, which was presented to the Pediatric Orthopedic Society of North America in 2003 [30]. The primary outcome of this study was malunion at two years, which was defined as greater than 2 cm of limb length discrepancy, greater than 15° of angulation in the sagittal plane or 10° in the coronal plane. The rate of malunion in the hip spica group was 45% compared to 16% in the external fixator group. There was no difference in functional outcome, parental or child satisfaction. The criteria for malunion may seem a little stringent, however, it should be recognized that these criteria were applied at two years of follow-up after the majority of remodelling would have occurred. In his study there was only one re-fracture in the external fixator group of 45 patients. This study shows the advantages of an RCT, even when the assumption is made that there is little clinical outcome difference between the two groups. The Cincinnati group has examined its cohorts treated with traction, followed by spica casting, compared with ESIN and found no difference in clinical and functional criteria. They found that elastic nailing was less costly than traction followed by spica casting because of the prolonged stay for the latter and that parents were more satisfied with elastic nailing [4]. Although it is tempting to believe that a trial of external fixation versus elastic nailing would be the next logical step, it should be recognized that both produce a high percentage of very satisfactory results clinically, functionally and in terms of satisfaction and that therefore it would be very difficult to conduct a sufficiently large trial to produce a meaningful outcome. Wright’s earlier work had suggested that hip spica treatment was consistently cheaper than external fixation, even when considering the range of complications, however, given the number of secondary surgeries in the hip spica group in his RCT, it is likely that these relative costs will be reversed.
Conservative methods As a child gets older, approaching adulthood and skeletal maturity, conservative methods become increasingly inappropriate for managing femoral shaft fractures. Management in a hip spica is impossible in the older child or adolescent. Traction methods require the placement of skeletal traction pins and the tendency is towards malunion, shortening and prolonged treatment times. It is more than 20 years since the disadvantages of traction and the advantages of intramedullary nailing of adolescent femoral fractures were first pointed out.
Elastic nailing Elastic nailing of the adolescent femoral shaft fracture can be performed using the same techniques described earlier. Currently, the largest available diameter of elastic nail is 4 mm. Two 4 mm nails are the appropriate implants for femoral shafts with an isthmus diameter of 10–12 mm. The intramedullary canals of adolescents are never larger than this, so larger diameter elastic nails would not be appropriate. The concern about elastic nails is whether they are strong enough to stabilise the fractures of heavier children. There is no definitive advice available in the literature, but there is a feeling among surgeons that 50 or 60 kg is the upper limit of child weight in which elastic nailing of the femoral shaft is appropriate. I have personally used elastic nails to stabilize a femoral shaft fracture in a boy who weighed 61 kg. There is no doubt that the method can be used with caution in this age and size of child. A brief period of bed rest or use of a femoral brace after the operation may be required.
Plate osteosynthesis Plates can be applied to adolescent femoral shaft fractures using both conventional and minimally invasive techniques. Plate configurations that achieve relative stability are most appropriate for adolescents and good results have been reported.
Locked intramedullary nailing The use of conventional adult pattern femoral nails for shaft fractures in adolescents is the most controversial area in this subject. The effectiveness of intramedullary nailing for the treatment of
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the adolescent femoral shaft is beyond doubt [32]. Several relatively large series have been published demonstrating the success of the implant in achieving length, alignment, and union [11]. The problem is the incidence of avascular necrosis of the femoral head that has been associated with the use of intramedullary nailing in children and adolescents [3, 26]. 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 considerably at risk from a nail that uses the piriformis fossa start point, or indeed one that starts on the medial part of the greater trochanter and whose insertion involves reaming out the medial wall of the greater trochanter. There is no nail currently on the market that can guarantee to avoid both of these places, although a nail has been presented that is inserted through the lateral surface of the trochanter, with promising early results [20]. Nailing through the trochanter tip is said to be safe [27]. The incidence of avascular necrosis after intramedullary nailing in adolescence is unknown. Large series tend to report only a single case, suggesting an incidence of 1–2%, but with a very wide confidence interval. The Pediatric Orthopedic Society of North America (POSNA) surveyed its members and identified more than 30 cases, but with an unknown denominator. This question is therefore not going to be solved by scientific study and is a philosophical point. Avascular necrosis of the femoral head is a devastating and untreatable condition. Some take the view that it is unreasonable to expose the older child to this complication when there are a variety of satisfactory alternative treatment modalities available for the fracture. Avascular necrosis of the femoral head has never been reported with ascending elastic nailing or plating of the femur. The matter was debated in the Journal of Paediatric Orthopaedics in late 2002. Green alluded in that article to his personal series of 175 intramedullary nailings performed with careful technique, including initial reaming over a guide wire. There were no cases of avascular necrosis. Letts abandoned his series after a case of avascular necrosis, even though over 50 children had been successfully treated without complication. My personal preference is to avoid 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 fixa-
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tion or plating. There are particular problems in the United States of America where adolescent weights of over 120 kg are now routinely being seen. In these children, the biomechanical advantages of a nail are clear. If an intramedullary nail is to be used prior to physeal closure, then informed consent would need to refer to a 1–2% incidence of avascular necrosis and the very serious nature of the complication.
Conclusions Multiple methods are available for treating children’s femoral shaft fractures. Surgeons need to be familiar with them all. The major determinants in choosing a particular method are local circumstances, costs, and culture. There is emerging evidence that surgical stabilisation produces less malunion and greater parent satisfaction than treatment in a spica. Locked intramedullary nailing is associated with avascular necrosis of the femoral head, a rare but devastating complication.
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11. Galpin RD, Willis RB, Sabano N (1994) Intramedullary nailing of pediatric femoral fractures. J Pediatr Orthop; 14(2):184– 189. 12. Hedin H, Hjorth K, Rehnberg L, et al (2003) External fixation of displaced femoral shaft fractures in children: a consecutive study of 98 fractures. J Orthop Trauma; 17(4):250–256. 13. Herring J (2002) Tachdjian‘s Pediatric Orthopaedics. 3rd ed. Philadelphia London New York St Louis Sydney Toronto, WB Saunders. 14. Hull JB, Sanderson PL, Rickman M, et al (1997) External fixation of children‘s fractures: use of the Orthofix Dynamic Axial Fixator. J Pediatr Orthop B; 6(3):203–206. 15. Kregor PJ, Song KM, Routt ML Jr, et al (1993) Plate fixation of femoral shaft fractures in multiply injured children. J Bone Joint Surg Am; 75(12):1774–1780. 16. Large TM, Frick SL (2003) Compartment syndrome of the leg after treatment of a femoral fracture with an early sitting spica cast. A report of two cases. J Bone Joint Surg Am; 85A(11):2207–2210. 17. Ligier JN, Metaizeau JP, Prevot J, et al (1988) Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br; 70(1):74–77. 18. Luhmann SJ, Schootman M, Schoenecker PL, et al (2003) Complications of titanium elastic nails for pediatric femoral shaft fractures. J Pediatr Orthop; 23(4):443–447. 19. Mubarak SJ, Carroll NC (1979) Volkmann‘s contracture in children: aetiology and prevention. J Bone Joint Surg Br; 61-B(3):285–293. 20. Phillips J (2001) The management of paediatric femur fractures with a flexible interlocked intramedullary nail: preliminary results of the use of a new device. EPOS; Montpellier. 21. Scherl SA, Miller L, Lively N, et al (2000) Accidental and nonaccidental femur fractures in children. Clin Orthop; 96–105. 22. Schwend RM, Werth C, Johnston A (2000) Femur shaft fractures in toddlers and young children: rarely from child abuse. J Pediatr Orthop; 20(4):475–481. 23. Skaggs DL, Leet AI, Money MD, et al (1999) Secondary fractures associated with external fixation in pediatric femur fractures. J Pediatr Orthop; 19(5):582–586. 24. Staheli LT, Sheridan GW (1977) Early spica cast management of femoral shaft fractures in young children. A technique utilizing bilateral fixed skin traction. Clin Orthop; 162–166. 25. Sutcliffe JR, Wilson-Storey D, Mackinlay GA (1995) Children‘s femoral fractures: the Edinburgh experience. J R Coll Surg Edinb; 40(6):411–415. 26. Thometz JG, Lamdan R (1995) 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 Am; 77(9):1423–1426. 27. Townsend DR, Hoffinger S (2000) Intramedullary nailing of femoral shaft fractures in children via the trochanter tip. Clin Orthop; 113–118. 28. Wallace ME, Hoffman EB (1992) Remodelling of angular deformity after femoral shaft fractures in children. J Bone Joint Surg Br; 74(5):765–769. 29. Ward WT, Levy J, Kaye A (1992) Compression plating for child and adolescent femur fractures. J Pediatr Orthop; 12(5):626–632.
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30. Wright J, Wang E, Coyte P, et al (2003) A randomised trial comparing early hip spica application and external fixation for the treatment of pediatric femoral fractures. POSNA Annual Meeting; Amelia Island FL. 31. Wright JG (2000) The treatment of femoral shaft fractures in children: a systematic overview and critical appraisal of the literature. Can J Surg; 43(3):180–189. 32. Ziv I, Blackburn N, Rang M (1984) Femoral intramedullary nailing in the growing child. J Trauma; 24(5):432–434.
Correspondence address: Dr. James B. Hunter BA FRCSEd (Orth) Consultant Trauma and Paediatric Orthopaedic Surgeon Queen’s Medical Centre Nottingham, NG7 2UH, GB email: [email protected]