5 Tips to Prepare for Treating Pediatric Femur Fractures

When a femur fracture comes in through the ED, it is more often than not “operative”. When it appears on the schedule, the OR staff often only sees “ORIF femur”. With this in mind, there are several factors that will play an important role in optimizing your OR utilization.

1: Incorporate age & weight of the patient into the OR readiness
Separating your patients by age (and weight) will allow the OR to think like a pediatric orthopaedic surgeon. This will include bed, C-arm (and radiology tech), implants (with rep, if applicable), and other instruments needed. Discuss intubation (as opposed to LMA) with Anesthesia in order to provide complete muscle relaxation which can be helpful for obtaining length and can provide a more secure airway.
  • < 3 years old – this is usually a spica cast. The OR should have C-arm ready, casting supplies, a regular bed, and a spica table available. There is no prepping and draping needed, so letting them know this will save time and money (supplies). Having an extra set of hands, towels available for “belly space”, and Gore-Tex liners in the correct size range will be useful. (Editor note: many published guidelines state spica casting can be effective up to 5-6 years old.  Area of debate!)
  • 3-10 years old (and < 100 lbs.) – this is usually flex nails. The OR should have C-arm ready, usually a standard OR table (flat Jackson for larger kids), the flexible nail implants and instrumentation (with implant rep notified), an F-tool (femoral reduction tool), bone reduction clamps available, and any post-operative immobilization ready (casting supplies, braces, etc.).
  • > 10 years old (or > 100 lbs.) – this may be a locked nail. The OR should have C-arm ready, either a flat Jackson or fracture table (based on surgeon preference), the locked nail implants and instrumentation (with implant rep notified), an F-tool (femoral reduction tool), bone reduction clamps available, etc.
  • Miscellaneous – establishing standard circumstances will allow you to alert the OR if you will be doing something outside of the customary procedure to pivot more quickly. There may be instances where pinning (K-wires / Steinmann pins), cannulated screws (4.0-7.3 mm), dynamic hip screws, small or large fragment plating, submuscular plating, locked plating, or external fixation is needed.
2: Hip spica casting of femur fractures
  • Having all the items preoperatively, particularly the spica table, cast cart, cast saw, cast liners, moleskin, etc. will save time.
  • Ensure 3 sets of hands available (attending, resident, scrub tech) to effectively cast.
  • Enlist Anesthesia / circulating nurse to secure the ET tube / LMA and hands.
  • Prior to placement on the spica table, place liner and sufficient padding of the abdomen to allow space for breathing and eating.
  • Position spica table at the end of the able to allow for adequate access to obtain intra-operative images.
  • The scrub tech can hold the well leg as instructed.
  • The attending and resident can address the fractured extremity.
  • Ensure good (valgus/recurvatum) mold. Consider plaster as an initial layer prior to overwrapping with fiberglass.
3: Flexible nailing of femur fractures
  • Pre-operatively template for 80% canal fill for 2 nails (40% per nail). 3-4 mm nails are the most commonly used sizes. The majority of nails used are titanium (these allow for easier insertion to “make the turn” during insertion). If there is a drastic mismatch between canal width and patient weight, consider stainless steel (may need to special order).
  • Select standard OR table vs. flat Jackson based on patient size or preference. Must be able to get C-arm from hip to knee. Bump the hip appropriately and prep entire lower extremity into operative field in the event you need to open. Have a lateral drape available.
  • Have reduction tools available (F-tool, reduction clamps, etc.).
  • Bend the nails accordingly using only portion of the nail that will be used. This usually involves a C-shape about 3x the width of the bone or about the width of the thigh. An “extra” bend at the tip will allow for easier insertion.
  • Advance each nail to the fracture site, reduce the fracture, then sequentially advance each nail across the fracture.
  • Trim nails just short of final location, then final impact them to keep them less prominent, yet easily accessible for later removal.
4: Locked nailing of femur fractures
  • Obtain full-length pre-operative imaging of the femur.
  • Familiarize yourself with the implant of choice (size options, locking screw options, instrumentation, steps, etc.)
  • Template canal size and select implant accordingly.
  • Depending on canal size, trochanteric morphology, and skeletal maturity, locked nailing may not be indicated. Never use piriformis nails for pediatric patients.
  • Select bed (flat Jackson vs. fracture table) based on patient size and surgeon preference.
  • Ensure ipsilateral arm does not interfere with surgical procedure, particularly nail insertion and canal reaming.
  • Obtain orthogonal imaging of the starting point at the greater trochanter prior to prepping and draping. Prep higher than you think, usually to the ribs. Bring C-arm in on a 45 degree angle and work in conjunction with radiology tech to ensure efficiency. Consider “taping” a spot on the floor for the radiology tech to “park” the C-arm wheels. Note ideal amount of lateral for the starting point .
5: Plating of femur fractures
  • Template implant length accordingly, possibly from the uninjured side.
  • Determine if submuscular / bridge plating or compression plating will be used to ensure correct implant.
  • Ensure ipsilateral arm does not interfere with surgical procedure. Prep higher than you think, usually to the ribs. Have a lateral drape available.
  • Incorporate the proper use of “bumps” to control the sagittal plane .
  • Incisions proximally and distally (if submuscular plating is used) should be incorporated to control each end of the plate.
  • Pin proximally & distally when out to length followed by screw near fracture to bring bone to the plate. Places screws proximally and distally to complete the construct. Occasionally the provisional K-wires need to be removed prior to placing screw to allow the bone to “reduce” to the plate.
Lastly, enjoy the process and surgery! These can be extremely gratifying cases which make a huge difference in your patients’ (and their families’) lives.