Chapter 28 What Is the Best Treatment for Femoral Fractures?
Pediatric femoral shaft fractures are among the most common injuries treated by the orthopedic surgeon. These fractures represent 1.6% of all bony injuries in children,1–3 with the majority healing without any long-term sequelae. A review of recent literature illustrates that abuse and falls represent the most common mechanisms of injury for femoral fractures in children 4 years of age and younger. In children older than 11 years, the femoral shaft is much stronger, so fracture is more often caused by high-energy injuries, such as motor vehicle accidents or gunshot wounds.2,4–6
Initial evaluation includes a comprehensive history and physical examination evaluating for the presence of swelling, instability, and/or tenderness. Imaging begins with anteroposterior and lateral radiographs of the entire femur, as well as views of the hip and knee. Rarely, a bone scan or magnetic resonance imaging is valuable, such as in the diagnosis of stress fractures.7
OVERVIEW
Femoral fractures are often separated into three broad categories according to the geographic location of the fracture, which include proximal femur fractures, femoral shaft fractures, and supracondylar femur fractures. The character of the fracture can also be classified based on its appearance: (1) transverse, spiral, or oblique; (2) comminuted or noncomminuted; and (3) open or closed.7 The nature of the injury, the character of the fracture, the child’s age, and the amount of soft-tissue involvement are important factors that ultimately influence treatment options.
Treatment options may be divided into traction/casting versus operative fixation management with the decision ultimately based on the child’s age, weight, and fracture stability. Closed reduction and casting is the treatment of choice in younger children, whereas fixation is used for older patients (Table 28-1).
TABLE 28-1 Treatment Options for Pediatric Femoral Shaft Fractures
| AGE | TREATMENT |
|---|---|
| Younger than 6 months |
In infants (birth to 6 months old), a stable proximal or midshaft femoral fracture can be treated with a simple splint or Pavlik harness. An infant with an unstable femoral fracture may need a Pavlik harness with a splint around the thigh to provide extra support. Immediate spica casting may be required in infants who present with femoral fractures of excessive shortening or angulation.7 A Pavlik harness facilitates skin care but does not offer the pain relief of full immobilization in a spica cast.
For children 6 months to 4 years of age, immediate (or early) spica casting is the method of choice for femoral fractures with less than 2 cm of initial shortening. Children in this age group with greater than 2 cm of initial shortening may require 3 to 10 days of skeletal traction followed by spica casting.7 In rare cases, external fixation and flexible intramedullary nailing (FIN) are used in this age group.
For children 4 to 11 years old, many treatment methods can be used, based on the surgeons’ preference, fracture type, and family’s wishes. Treatment options include early spica casting, skeletal traction followed by spica casting, FIN, plate fixation, solid antegrade nailing, and external fixation.7 The optimal treatment for femur fractures in this 4- to 11-year-old age group is based on the nature of the injury, the character of the fracture, the skeletal maturity, the patient’s weight, and the experience and skill of the surgeon with a given treatment method.
Children 11 years of age to skeletal maturity require maximum fixation strength whereas avoiding avascular necrosis or growth arrest. Treatment options include FIN, plating, locked intramedullary nails, and external fixation.7 Rigid, locked intramedullary nailing utilizes a trochanteric starting point and is popular particularly in those children who are closer to skeletal maturity. Submuscular plating is becoming increasingly popular for this age group. Traction followed by spica casting, which was a standard treatment in the 1990s, is rarely used for this age group today (Fig. 28-1).8
EVIDENCE
Six Months to 4 Years
Several studies have shown that both the Pavlik harness (younger than 6 months) and spica casting (6 months to 4 years of age) are acceptable treatment options (Table 28-2). A retrospective study (Level III evidence) of 40 patients by Podeszwa and colleagues9 compared application of the Pavlik harness versus spica casting for the treatment of children younger than 1 year. No difference was found in radiographic outcomes, but approximately one third of all spica patients experienced development of a skin complication. The authors conclude that all children younger than 1 year with a femoral shaft fracture should be considered for treatment with a Pavlik harness.9 Buckley10 reports the current trends in the treatment of femoral shaft fractures in children and adolescents. By analyzing healthcare costs and the desire for early discharge, he concludes that immediate hip spica casting remains the optimum method of treatment for most children 4 years and younger (Level III evidence). Allen and colleagues11 likewise recommend immediate spica casting for femoral shaft fractures in infants and children. They reviewed 55 femoral shaft fractures in children treated by closed reduction and immediate application of a double hip spica cast, and showed satisfactory results in all cases (level IV evidence case series, but with uniform outcome).11 In a study comparing spica casting and skeletal traction, Wright12 shows that early application of a hip spica cast had lower costs and malunion rates than traction (Level II evidence).
| STUDY | LEVEL OF EVIDENCE | GRADE OF RECOMMENDATION |
|---|---|---|
| Podeszwa et al.9 | III | B |
| Buckley10 | III | B |
| Allen et al.11 | IV | c |
| Wright12 | II | B |
| Bar-On et al.13 | II | B |
| Barlas et al.14 | III | B |
| Caird et al.15 | IV | C |
| Ward et al.16 | IV | C |
| Caglar et al.17 | III | B |
| Sink et al.18 | IV | B |
| Kanlic et al.19 | III | B |
| Buechsenschuetz et al.20 | II | B |
| Flynn et al.21 | II | B |
| Wright et al.22 | I | A |
| Coyte et al.23 | III | B |
| Carey et al.24 | III | B |
| Aronson et al.25 | IV | C |
| Davis et al.26 | IV | C |
| Domb et al.27 | II | B |
| Leet et al.28 | III | B |
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