Study Guide

Femur Fracture

Key Points:

Description:

Femoral diaphyseal fractures account for nearly 2 percent of all bony injuries in children, and are the most common orthopedic injury requiring hospitalization.(Sahlin, 1990;McCartney, 1994;Flynn, 2004)  In the past,  femur fractures in all children were commonly treated with immediate spica casting or a period of traction followed by casting.(Flynn, 2001)  Non-surgical treatment with spica casting remains the standard for infants and toddlers less than 5 years; however, school-age children are now more commonly undergoing surgical intervention.  Surgical treatment has reduced the burden of care for families, shortened hospital stays, and decreased the early disability and disruption in the families’ lives.(Hughes, 1995; Karn, 1986; Kirby, 1981; Buechsenschuetz, 2002) 

Epidemiology:

Trauma is the leading cause of death and disability in children.(Waller, 1989;Haller, 1983;Peclet, 1990)  When evaluated in the late 1990’s, orthopaedic trauma led to 84,000 hospital admissions annually and a cost of nearly a billion dollars.(Galano, 2005)  Femur fractures were the most common reason for admission in this group.  Males more commonly sustain femur fractures, as they account for greater than 70% of injuries. There is a bimodal age distribution of fractures, first in early childhood then again peaking in adolescence.  Falls and motor vehicle collisions are the most common mechanisms of injury, accounting for approximately two thirds of the injuries in older children.  In younger children, a fall is the most common mechanism.  Fifteen percent of femur fractures in children under 2 years and up to 80% of fractures before walking age are the result of non-accidental trauma.(Loder, 2006; Beals, 1983; Blakemore, 1996; Gross, 1983)  Transverse fractures may be a better predictor of nonaccidental trauma in young children as compared to spiral fractures.(Murphy, 2015)

Clinical Findings:

In the setting of suspected femur fracture, it is critical that the entire child is examined as associated injuries are common.  Typical physical exam findings associated with femur fracture include: deformity, thigh swelling, and pain.  However, more subtle findings may be present in the small child.  Hemodynamic instability and significant drop in hematocrit are rarely present in a child with an isolated femur fracture and should alert the physician to look for associated injuries.(Ciarallo, 1996; Lynch, 1996) 

Imaging Studies:

X-ray evaluation should include the whole femur, as associated injuries such as an ipsilateral physeal fracture about the knee or a femoral neck fracture can occur.  Plain radiographs are usually sufficient for establishing the diagnosis and for preoperative planning.

Classification

Fractures are classified by pattern, location, stability, and whether the fractures are open or closed.  Fracture patterns include: transverse, short oblique, spiral, and comminuted.  Level of the fracture on the femur is important, as displacement of the fracture pieces is characteristic based on the muscle attachment points and the forces applied to the fractured pieces. Stability of the fracture influences treatment.  Transverse fractures are considered “length-stable” and some oblique or comminuted fractures are considered “length-unstable”.  Open fractures are classified by the system of Gustilo and Anderson.(Gustilo, 1976)

Treatment:

Treatment of femur fractures varies by age, fracture pattern, mechanism, weight of the child, and associated injuries.  No clear consensus has been reached regarding optimal treatment, despite attempts at the creation of formal guidelines.(Kocher, 2010)  There are a number of trendswhich have emerged to help guide management based on the above characteristics.  Femur fractures in a child under 6 months are typically well-treated in a Pavlik harness or spica cast. For children 6 months to 5 years, spica casting (with or without pre-casting traction) has been shown by multiple studies to give good results.(Rasool, 1989; Burton, 1972)  In patients 5-11 years of age, femur fractures may be treated with flexible nails, submuscular or open plating, or external fixation.  Children 12 years of age and older may be treated with rigid intramedullary nailing using either a trochanteric or lateral-trochanteric starting point to minimize potential injury to the blood supply of the proximal femoral epiphysis or submuscular plating.  Each treatment type has risks and benefits and may be more suited to a particular fracture pattern or patient characteristic.  For example, unstable fracture patterns (oblique or comminuted) may be more difficult to control with flexible intramedullary nails and may be better suited to plating or rigid nailing.  See table summarizing range of treatment options; the exact ages for transition between treatment types remains controversial and is debated.  (Table 1).
 
Table 1. Treatment options based on patient and fracture characteristics.
Age Weight Fracture Stability
(Length Stable vs. Unstable*)		 Treatment Options
< 6 mo Any Any Pavlik harness
Spica Cast
6 mo – 5 yrs Any Stable and Most unstable Spica cast
 
  Any Some unstable 90/90 traction à spica cast
Flexible nails (controversial)
5 – 11 yrs. < 49 kg Stable Flexible intramedullary nailing
 
  Any Unstable Submuscular bridge plate vs. External fixation
 
  > 49 kg Any Submuscular bridge plate vs. External fixation vs. Rigid trochanteric entry nail (in older children, but controversial)
> 11 yrs. < 49 kg Stable Rigid trochanteric entry nail vs. Flexible intramedullary nailing
  > 49 kg Any Rigid trochanteric entry nail vs. submuscular plate
Special Situations      
Polytrauma or open fracture     Consider external fixation
Severe Comminution     External fixation vs. submuscular plating (consider use of rigid trochanteric entry nail in older kids)
*Length stable fractures have a transverse fracture pattern.  Oblique and comminuted fracture patterns considered length unstable

Complications:

Many of the complications associated with femur fracture treatment are unique to the particular treatment modalities, though there are some sequelae common to all treatment types.  The most common complication is leg length discrepancy.  Particularly with nonoperative treatment, shortening is common. However, overgrowth of the bone after union often “makes up” the difference and can lead to a longer extremity on the injured side. This can occur in a wide range of ages but is thought to be most common in children age 2-4 years. Angular deformity is also common with nonoperative treatment, but some degree of angular deformity would be expected to remodel with growth.  Acceptable alignment by age shown below (Table 2).  Operatively treated fractures carry the additional risk of surgical site infection and wound complications as well as hardware-related pain or breakage.  Refracture following hardware removal is a potential problem, most notably with fractures managed with external fixation.  Complications related to flexible intramedullary nailing has been extensively studied, with reported rates ranging from 10-62% (Flynn, 200; Flynn, 2002; Moroz, 2006; Heinrich, 1994; Sink, 2005; Narayanan, 2004; Mazda, 1997; Sink, 2010).  Malrotation with at least 15 degrees of external torsion has been noted in nearly 50% of patients after flexible nailing, irrespective of fracture pattern. (Salem, 2010)  Case reports of femoral head AVN and trochanteric growth arrest with the use of rigid nailing has generally limited the use of this technique to older children. However, there are no reports of AVN associated with lateral entry trochanteric rigid nailing, with complication rates of rigid nailing reported as high as 10%. (MacNeil, 2011; Miller, 2012; Keeler, 2009; Crosby, 2014)   Submuscular plating was recently reported to have a complication rate of 13% (6% major, 7% minor), mostly due to plate retention, at mean 20 month follow up. (May C, 2013).
Table 2. Acceptable shortening and angulation measurements of femur fractures based on age.
Age Varus/Valgus (degrees) Anterior/Posterior (degrees) Shortening (mm)
 
Birth to 2 yr. 30 30 15
2 – 5 yr. 15 20 20
6 – 10 yr. 10 15 15
11 yr. to maturity 5 10 10
Adapted from Beaty JH and Kasser JR, Rockwood and Wilkins Fractures in Children, 7th Ed.(Beaty JH, 2010 #133)


 

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Collin May MD
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