Femoral Shaft Fractures in Children

1. Femoral Shaft Fractures in Children Original: M.L. Routt, Jr., M.D. Revised October, 2011: Andrew R. Evans, M.D. Most of the Presenter�s notes/Commentary, as well as many of the clinical photographs and radiographs included in this updated presentation were provided by Dr. Routt in his original version of this presentation.Most of the Presenter�s notes/Commentary, as well as many of the clinical photographs and radiographs included in this updated presentation were provided by Dr. Routt in his original version of this presentation.

2. Pediatric Femoral Shaft Fractures One of the most common pediatric lower extremity fractures Most common pediatric fracture requiring hospital admission.

3. Treatment Options Traction Spica Casting Pins & Plaster External Fixation Internal Fixation Plate/Screws Flexible nails Rigid Intramedullary rods - trochanteric vs. lateral entry Dr. Routt: I work at HarborView Medical Center in Seattle. I would like to encourage all of you to pursue a career in trauma. I think it is the greatest thing in the whole world (I am very biased). I guess that is why you are here - to learn about fractures and perhaps sort out your career as well. Hopefully, I will get to know all of you at some point during the application process as you look for fellowships. I am sure that you will all want to do orthopaedic trauma after all the time you have spent here learning about these things. I think femoral shaft fractures in children are a little difficult to deal with, especially if you are taking care of them sporadically and especially when they are associated with polytrauma. Isolated femoral shaft fractures are a little bit different. Image 1 is the treatment of a little baby I saw when I was over in England working with Chris Colton. I had not previously seen this form of traction. It was condemned in the United States but I learned rapidly when you go across the pond things change and what we may condemn, they may use on a routine basis. You can skin a cat a lot of different ways. Everything has its own set of problems. When taking care of children with femoral shaft fractures, there are several options. Traction has a long, well established history. One can use traction followed by a spica cast. One can use an early spica cast or the more invasive options (external fixation, intramedullary rod or plate internal fixation). You can put something around the skin or through the skin or on the bone or in the bone - or you can use combinations.Dr. Routt: I work at HarborView Medical Center in Seattle. I would like to encourage all of you to pursue a career in trauma. I think it is the greatest thing in the whole world (I am very biased). I guess that is why you are here - to learn about fractures and perhaps sort out your career as well. Hopefully, I will get to know all of you at some point during the application process as you look for fellowships. I am sure that you will all want to do orthopaedic trauma after all the time you have spent here learning about these things. I think femoral shaft fractures in children are a little difficult to deal with, especially if you are taking care of them sporadically and especially when they are associated with polytrauma. Isolated femoral shaft fractures are a little bit different. Image 1 is the treatment of a little baby I saw when I was over in England working with Chris Colton. I had not previously seen this form of traction. It was condemned in the United States but I learned rapidly when you go across the pond things change and what we may condemn, they may use on a routine basis. You can skin a cat a lot of different ways. Everything has its own set of problems. When taking care of children with femoral shaft fractures, there are several options. Traction has a long, well established history. One can use traction followed by a spica cast. One can use an early spica cast or the more invasive options (external fixation, intramedullary rod or plate internal fixation). You can put something around the skin or through the skin or on the bone or in the bone - or you can use combinations.

4. Pediatric Femoral Shaft Fractures Treatment is often directed by the patient�s age 0-6 months 6 months - 5 years 5 - 11 years 11 years - skeletal maturity Other considerations Additional injuries, social situation, physician preference, etc. Dr. Routt: Generally people have decided treatment according to age (i.e. kids less than two years old, two to five and greater than six ). I think this is somewhat in transition as people become more aggressive surgically. We heard a nice speech yesterday by Dr. Sarmiento about the surgical over-zealousness and how this has changed a lot of things . We have to realize that there is a good history of closed management of isolated femoral shaft fractures in children. Although in their treatment algorithm, most people focus the age of the patient, there are special concerns with respect to the polytraumatized pediatric population. This is a small group but it does exist. The care of a pediatric polytraumatized patient usually involves a lot of other issues. The majority of children that are polytraumatized seem to have complex social situations as well. In treating these patients, you have to recognize the person in the mirror. If you don't know how to do certain things, that doesn't mean you have to deny the patient. Don't be reluctant to obtain the assistance of a colleague who knows how to do good plating, or someone who knows how to do good external fixation in order to help you to take care of these patients more effectively. Figure: Treatment options for pediatric femoral fractures based on type of injury and patient age. Flynn et. al.Dr. Routt: Generally people have decided treatment according to age (i.e. kids less than two years old, two to five and greater than six ). I think this is somewhat in transition as people become more aggressive surgically. We heard a nice speech yesterday by Dr. Sarmiento about the surgical over-zealousness and how this has changed a lot of things . We have to realize that there is a good history of closed management of isolated femoral shaft fractures in children. Although in their treatment algorithm, most people focus the age of the patient, there are special concerns with respect to the polytraumatized pediatric population. This is a small group but it does exist. The care of a pediatric polytraumatized patient usually involves a lot of other issues. The majority of children that are polytraumatized seem to have complex social situations as well. In treating these patients, you have to recognize the person in the mirror. If you don't know how to do certain things, that doesn't mean you have to deny the patient. Don't be reluctant to obtain the assistance of a colleague who knows how to do good plating, or someone who knows how to do good external fixation in order to help you to take care of these patients more effectively. Figure: Treatment options for pediatric femoral fractures based on type of injury and patient age. Flynn et. al.

5. Femoral Shaft Fractures: 0 - 6 Months 40% of femoral diaphyseal fractures in patients <1 year of age are non-accidental Child Abuse - approximately 15% of femoral shaft fractures in patients <36 months of age result from abuse >90% of pediatric femoral shaft fractures resulting from abuse occur in children <36 months of age

6. Femoral Shaft Fractures: 0 - 6 Months AAOS Clinical Practice Guideline: All children < 36 months of age with a diaphyseal femur fracture must be evaluated for child abuse Complete History & Physical examination Consultation with Pediatrician, Family Practitioner, and/or Child Abuse Team Skeletal survey if warranted

7. Femoral Shaft Fractures: 0 - 6 Months Pavlik harness Stable union typically achieved within 5 weeks Spica casting Higher risk of skin complications than Pavlik Waterproof cast liners improve sanitation Spica casting with incorporated distal femoral traction pin May decrease incidence of unacceptable shortening and frontal plane malalignment

8. Femoral Shaft Fractures: 6 months - 5 years Diaphyseal Femur Fractures: <2cm shortening Early spica casting (90�/90�) Enhanced ease of care Shorter hospital stay No defined optimal weight range Spica casting in ED versus OR yield similar reduction quality and complication rates Traction with delayed spica casting Skin traction typically ineffective; skeletal traction often required

9. Femoral Shaft Fractures: 6 months - 5 years Diaphyseal Femur Fractures: > 2cm shortening Spica casting Insufficient evidence to recommend for/against (AAOS Clinical PracticeGuideline) Mode of treatment may be altered if deemed necessary External fixation Lower incidence of malunion compared to spica casting Flexible IM nailing may be considered for the oldest, most mature patients in this age group Dr. Routt: Immediate spica casting was popularized by Ben Allen from Galveston. Other authors have advanced this technique by doing early fluoroscopic evaluations under anaesthesia to see how much pistoning occurs. Dave Thompson and his group have looked at the exam under fluoroscopy and found it to be quite predictable. Depending on the amount of pistoning or shortening these limbs, a decision is made as to who can be put into an immediate spica and who can't. This facilitates early discharge and health care cost reductions at the expense of a possibility of a little bit of limb shortening. Some people believe that shortening in a spica cast can be addressed if you know how to put on a good cast with a good buttock and supracondylar mold. In the Galveston series published in The Journal of Trauma, they put on a long leg cast with a really tight supracondylar mold in the ER the same day of the injury. This long leg cast was then converted into a spica with the child under sedation. The child was discharged home straight away - assuming the social support was adequate . But this required adequate molding of the cast. You can't put a tubular plaster onto an extremity and expect that it is going to maintain length and reduction.Dr. Routt: Immediate spica casting was popularized by Ben Allen from Galveston. Other authors have advanced this technique by doing early fluoroscopic evaluations under anaesthesia to see how much pistoning occurs. Dave Thompson and his group have looked at the exam under fluoroscopy and found it to be quite predictable. Depending on the amount of pistoning or shortening these limbs, a decision is made as to who can be put into an immediate spica and who can't. This facilitates early discharge and health care cost reductions at the expense of a possibility of a little bit of limb shortening. Some people believe that shortening in a spica cast can be addressed if you know how to put on a good cast with a good buttock and supracondylar mold. In the Galveston series published in The Journal of Trauma, they put on a long leg cast with a really tight supracondylar mold in the ER the same day of the injury. This long leg cast was then converted into a spica with the child under sedation. The child was discharged home straight away - assuming the social support was adequate . But this required adequate molding of the cast. You can't put a tubular plaster onto an extremity and expect that it is going to maintain length and reduction.

10. Femoral Shaft Fractures: 6 months - 5 years Insufficient evidence exists to recommend any specific degree of angulation, rotation, or shortening that is unacceptable (AAOS Clinical Practice Guideline) Traditionally: Varus/valgus deformity more poorly tolerated than flexion/extention deformity Up to 30� of rotational malunion can be tolerated Remodelling occurs to a greater extent in younger children with more growth potential Overgrowth is a biologic response to fracture in this age group but is unpredictable

11. Femoral Shaft Fractures: 5 - 11 years Skeletal Traction Typically used to precede definitive treatment particularly in severely traumatized patients Spica casting Poorly tolerated, Higher risk of malunion Dr. Routt: Home traction has a good track record and has become a little bit more popular. You may have seen some patients in your training who were treated in this manner. However, sorting out who and who not to send home can be a bit dicey - especially when you are sending them home in skeletal traction. This requires pin care, very reliable parents (someone to get the child out of the house if the house is going to burn down). You can't just leave this person unattended in the bed. They always say "Well, our house isn't going to burn down." Well, the child wasn't going to break his leg either. So things happen. You also usually need mobile radiology with these kids as you need to have some way of assessing the length, alignment and the rotation of the limb in home traction. So there are some requirements that go along with using home traction. If you use more invasive measures such as putting a skeletal pin adjacent to a distal femoral physis (which I would consider a bit invasive if it was my child), I would advise the use of fluoroscopy and radiographic follow-up. Procedure - Lower Extremity Skeletal Traction When I was in Britain, they would palpate the fracture on daily ward rounds. When the fracture was non-tender to palpation the patient would be converted to a spica. Non-tender to palpation meant that there was enough callus to maintain leg length in the spica. Of concern in the conversion from traction to a spica cast is shortening. Traction is used for an initial period to prevent the shortening. Image 2 shows there is still some bayonet apposition on this child's femoral shaft fracture. Most people anticipate an overgrowth because of the fractured limb hyperemia which is postulated to stimulate the distal and proximal femoral physes. This phenomenon of overgrowth is not entirely understood and so the shortening issue is still in a little bit of a debate. One needs to consider the cost of traction before conversion to spica in our health system. It may be difficult to justify keeping a child in the hospital in traction for two weeks or until there is enough callus for spica cast conversion. Lynn Staheli has studied this subject extensively. (Staheli, Sheridan; Early Spica Cast Management of Femoral Shaft Fractures in Young Children; CORR 126:162 1977)Dr. Routt: Home traction has a good track record and has become a little bit more popular. You may have seen some patients in your training who were treated in this manner. However, sorting out who and who not to send home can be a bit dicey - especially when you are sending them home in skeletal traction. This requires pin care, very reliable parents (someone to get the child out of the house if the house is going to burn down). You can't just leave this person unattended in the bed. They always say "Well, our house isn't going to burn down." Well, the child wasn't going to break his leg either. So things happen. You also usually need mobile radiology with these kids as you need to have some way of assessing the length, alignment and the rotation of the limb in home traction. So there are some requirements that go along with using home traction. If you use more invasive measures such as putting a skeletal pin adjacent to a distal femoral physis (which I would consider a bit invasive if it was my child), I would advise the use of fluoroscopy and radiographic follow-up. Procedure - Lower Extremity Skeletal Traction When I was in Britain, they would palpate the fracture on daily ward rounds. When the fracture was non-tender to palpation the patient would be converted to a spica. Non-tender to palpation meant that there was enough callus to maintain leg length in the spica. Of concern in the conversion from traction to a spica cast is shortening. Traction is used for an initial period to prevent the shortening. Image 2 shows there is still some bayonet apposition on this child's femoral shaft fracture. Most people anticipate an overgrowth because of the fractured limb hyperemia which is postulated to stimulate the distal and proximal femoral physes. This phenomenon of overgrowth is not entirely understood and so the shortening issue is still in a little bit of a debate. One needs to consider the cost of traction before conversion to spica in our health system. It may be difficult to justify keeping a child in the hospital in traction for two weeks or until there is enough callus for spica cast conversion. Lynn Staheli has studied this subject extensively. (Staheli, Sheridan; Early Spica Cast Management of Femoral Shaft Fractures in Young Children; CORR 126:162 1977)

12. Femoral Shaft Fractures: 5 - 11 years External Fixation Lower incidence of malunion than spica casting Ease of hardware removal compared to plates or nails Risk of re-fracture, pin site infection, scarring/stiffness of IT band Excellent mode of provisional fixation Dr. Routt: External fixation is more invasive because instead of putting just one pin across the distal metaphysis, you are now starting to load up the leg with pins. In the polytraumatized child or a child with a floating extremity or open injuries this tends to have some merit. We typically use a lateral construct . It allows rapid mobilization of patients from the recumbent position. It is especially helpful in the head injured and it does maintain a more substantial fracture control. Sometimes the ex-fix frame can bail you out but it has its share of problems. There are the pin tract or bone infections, as Dr. Chapman just mentioned. You have to remove this device and that means you may have to do it in the clinic. A lot of kids don't tolerate removal of four Shanz pins in the clinic. You also may need to curettage the tracks which sometimes necessitates taking them back to the operating room a second time. In The Journal of Orthopaedic Trauma, Paul Gregory has published a nice series on external fixation. Refracture can happen - not only at the fracture site because the frames may be removed too soon but also fractures through the pin sites. There is also the problem with the ITB (iliotibial band). If we go back to the previously mentioned case of the boy, you can see that he doesn't want to bend his knee much on the right. When you place the pin, you may want to make a nice stellate incision distally over the iliotibial band. This allows the iliotibial band to move and permit a full range of knee motion. If you make just an ITB linear incision to place your pin with the knee in extension or a little bit of flexion, then the ITB tethers the knee in extension and the child won't bend the knee. The rehab doctors will call you from the children's ward and they will say, "Why don't you do something.? I can't get this child to bend their knee and the frame is clacking on their walker." Streamline your frames and with knee range of motion in mind. Focus on the reduction and on the technique of frame application but also think about the aftercare when you are doing it.Dr. Routt: External fixation is more invasive because instead of putting just one pin across the distal metaphysis, you are now starting to load up the leg with pins. In the polytraumatized child or a child with a floating extremity or open injuries this tends to have some merit. We typically use a lateral construct . It allows rapid mobilization of patients from the recumbent position. It is especially helpful in the head injured and it does maintain a more substantial fracture control. Sometimes the ex-fix frame can bail you out but it has its share of problems. There are the pin tract or bone infections, as Dr. Chapman just mentioned. You have to remove this device and that means you may have to do it in the clinic. A lot of kids don't tolerate removal of four Shanz pins in the clinic. You also may need to curettage the tracks which sometimes necessitates taking them back to the operating room a second time. In The Journal of Orthopaedic Trauma, Paul Gregory has published a nice series on external fixation. Refracture can happen - not only at the fracture site because the frames may be removed too soon but also fractures through the pin sites. There is also the problem with the ITB (iliotibial band). If we go back to the previously mentioned case of the boy, you can see that he doesn't want to bend his knee much on the right. When you place the pin, you may want to make a nice stellate incision distally over the iliotibial band. This allows the iliotibial band to move and permit a full range of knee motion. If you make just an ITB linear incision to place your pin with the knee in extension or a little bit of flexion, then the ITB tethers the knee in extension and the child won't bend the knee. The rehab doctors will call you from the children's ward and they will say, "Why don't you do something.? I can't get this child to bend their knee and the frame is clacking on their walker." Streamline your frames and with knee range of motion in mind. Focus on the reduction and on the technique of frame application but also think about the aftercare when you are doing it.

13. Femoral Shaft Fractures: 5 - 11 years Flexible (Elastic) Intramedullary Nails Preferred method for treatment of most femoral disphyseal fractures in this age group Titanium or stainless steel (Enders) Antegrade or retrograde (more common) insertion Outcomes best when used to treat stable fracture patterns Shorter hospital stay Fewer adverse events More rapid return to school Most common complication is irritation at distal insertion sites Increased risk of poor outcome in children weighing >108 lbs (49kg) Dr. Routt: Elastic medullary fixation was popularized by a report by Ligier JBJS B 70:74 (1988) in a series on Metaizeau elastic medullary fixation. Metaizeau rods are just like Enders rods or Rush rods which are inserted into the distal femur. Image 2 shows a paraplegic child treated with a Rush rod in1986. Rapid healing is apparent by two months. Of course, this requires an operation. Sometimes these kids are having other operations and you can add on this type of fixation. The fixation still has a little bit of instability. This is a small metallic implant within a tubular structure which it does not fill. You can still have rotational, angulatory as well as shortening problems in situations of comminution. Also, most people would say there is another problem because now you have an implant that needs to be removed because it is a growing child.Dr. Routt: Elastic medullary fixation was popularized by a report by Ligier JBJS B 70:74 (1988) in a series on Metaizeau elastic medullary fixation. Metaizeau rods are just like Enders rods or Rush rods which are inserted into the distal femur. Image 2 shows a paraplegic child treated with a Rush rod in1986. Rapid healing is apparent by two months. Of course, this requires an operation. Sometimes these kids are having other operations and you can add on this type of fixation. The fixation still has a little bit of instability. This is a small metallic implant within a tubular structure which it does not fill. You can still have rotational, angulatory as well as shortening problems in situations of comminution. Also, most people would say there is another problem because now you have an implant that needs to be removed because it is a growing child.

14. Femoral Shaft Fractures: 5 - 11 years Sub-muscular plating Compression versus bridging plate techniques Open reduction versus minimally invasive plate osteosynthesis (MIPO) May address stable or unstable fracture patterns effectively Indications for plate removal remain controversial Anteroposterior (A) and lateral (B) radiographs of a grade III open segmental midshaft femoral fracture in an 11-year-old boy. C, Anteroposterior radiograph taken 3 months after internal fixation with a 4.5-mm limited-contact dynamic-compression plate, demonstrating excellent interval healing. Screws were placed percutaneously, and periosteal stripping was kept to a minimum. D, Anteroposterior radiograph taken 14 months after surgery. The fracture is well healed. There were no complications. (Courtesy of Enes Kanlic, MD, PhD, El Paso, TX.)Anteroposterior (A) and lateral (B) radiographs of a grade III open segmental midshaft femoral fracture in an 11-year-old boy. C, Anteroposterior radiograph taken 3 months after internal fixation with a 4.5-mm limited-contact dynamic-compression plate, demonstrating excellent interval healing. Screws were placed percutaneously, and periosteal stripping was kept to a minimum. D, Anteroposterior radiograph taken 14 months after surgery. The fracture is well healed. There were no complications. (Courtesy of Enes Kanlic, MD, PhD, El Paso, TX.)

15. Femoral Shaft Fractures: 11 years - Skeletal Maturity External Fixation Useful to achieve provisional fixation of femoral fractures in severely injured patients or open fractures May be used for definitive treatment of subtrochanteric or distal metadiaphyseal fractures that are less amenable to plate or nail fixation Avoids direct fracture exposure, minimizes blood loss, minimizes risk of physeal injury More frequent complications include delayed union and refracture after device removal Dr. Routt: It worked great for this boy. He had intracranial pressures of 70 for about two weeks and was not well. We were allowed by the neurosurgeons to do something to stabilize his femur the night of his injury. They preferred something that wouldn't involve a large blood loss so they could control his fluid flux and cerebral edema. With the help of a fixator, we positioned him up almost in the standing position to diminish some of the intracranial pressure. Two weeks later his pressures were much improved.Dr. Routt: It worked great for this boy. He had intracranial pressures of 70 for about two weeks and was not well. We were allowed by the neurosurgeons to do something to stabilize his femur the night of his injury. They preferred something that wouldn't involve a large blood loss so they could control his fluid flux and cerebral edema. With the help of a fixator, we positioned him up almost in the standing position to diminish some of the intracranial pressure. Two weeks later his pressures were much improved.

16. Femoral Shaft Fractures: 11 years - Skeletal Maturity Flexible intramedullary nails Outcomes optimized when use is limited to stable fracture patterns Higher risk of complications in patients >11 years of age, >108 lbs (49kg), and unstable fracture patterns Commonly reported complications: knee pain at insertion site, nail prominence, nail migration, fracture shortening/malunion, delayed union Dr. Routt: We used Enders technique a lot at Vanderbilt when I was there in my training. We used retrograde Enders nails from medial and lateral portals and locked the implants with small 3.5 mm screws. You get a little bit better stability compared to a single implant like a Rush rod. The more canal fill - the better the fixation - in theory. Most people using this technique would still advocate some form of derotation control which means a spica cast. There is not much benefit if the patient still needs a spica cast.Dr. Routt: We used Enders technique a lot at Vanderbilt when I was there in my training. We used retrograde Enders nails from medial and lateral portals and locked the implants with small 3.5 mm screws. You get a little bit better stability compared to a single implant like a Rush rod. The more canal fill - the better the fixation - in theory. Most people using this technique would still advocate some form of derotation control which means a spica cast. There is not much benefit if the patient still needs a spica cast.

17. Femoral Shaft Fractures: 11 years - Skeletal Maturity Sub-muscular plating Compression versus bridging plate techniques Open reduction versus minimally invasive plate osteosynthesis (MIPO) May address stable or unstable fracture patterns effectively Accurate and stable reductions are achievable; malunions uncommon Dr. Routt: Phil Kregor (JBJS A 75:1774; 1993) and several others have written articles on plate fixation. Plate fixation of the femoral shaft fractures in children received bad publicity in the past because it had a high rate of infection. Three out of five pediatric femoral shaft fractures that were plated in a very small series by Ziv and Rang in JBJS B 65:276, 1983 (without preoperative or intraoperative antibiotics) were infected and caused generalized sepsis. This was a small sample and there were extenuating circumstances (all patients were head-injured) - but it discouraged the use of plate fixation. In our experience with plate fixation has been quite good. It is invasive. It provides stable fixation. Most people would advocate implant removal. There is a scarring issue because the children are growing. Growth hormone tends to give them a big scar. The infection issue, at least in the our series (JBJS A 75:1774; 1993), has been somewhat put to rest. With antibiotics, good sterile technique and careful handling the soft tissues this can be a very successful treatment.Dr. Routt: Phil Kregor (JBJS A 75:1774; 1993) and several others have written articles on plate fixation. Plate fixation of the femoral shaft fractures in children received bad publicity in the past because it had a high rate of infection. Three out of five pediatric femoral shaft fractures that were plated in a very small series by Ziv and Rang in JBJS B 65:276, 1983 (without preoperative or intraoperative antibiotics) were infected and caused generalized sepsis. This was a small sample and there were extenuating circumstances (all patients were head-injured) - but it discouraged the use of plate fixation. In our experience with plate fixation has been quite good. It is invasive. It provides stable fixation. Most people would advocate implant removal. There is a scarring issue because the children are growing. Growth hormone tends to give them a big scar. The infection issue, at least in the our series (JBJS A 75:1774; 1993), has been somewhat put to rest. With antibiotics, good sterile technique and careful handling the soft tissues this can be a very successful treatment.

18. Femoral Shaft Fractures: 11 years - Skeletal Maturity Submuscular plating: Open reduction with soft-tissue stripping fracture exposure may increase risk of non-union Risk of re-fracture if plate is removed Dr. Routt: You need to be wary of highly comminuted femoral shaft fractures which have some instability within the central area of the fracture - especially when these fractures come packaged with the ten year old with the Marlboro pack rolled up in his shirt sleeve. If you have never seen a ten year old with Marlboros in his shirt sleeve, stay tuned because they are coming at you. This boy was a little bit of a high velocity boy. He was riding his motorcycle about two weeks after we plated his femur. Mom and dad thought that was super. You can see how he gets some deformity. You can defeat almost any form of fixation so choose your patients carefully and try to get to know them and try not to just stick with one implant technology.Dr. Routt: You need to be wary of highly comminuted femoral shaft fractures which have some instability within the central area of the fracture - especially when these fractures come packaged with the ten year old with the Marlboro pack rolled up in his shirt sleeve. If you have never seen a ten year old with Marlboros in his shirt sleeve, stay tuned because they are coming at you. This boy was a little bit of a high velocity boy. He was riding his motorcycle about two weeks after we plated his femur. Mom and dad thought that was super. You can see how he gets some deformity. You can defeat almost any form of fixation so choose your patients carefully and try to get to know them and try not to just stick with one implant technology.

19. Femoral Shaft Fractures: 11 years - Skeletal Maturity Rigid intramedullary nailing - greater trochanteric entry femoral nail Well suited for unstable fracture patterns Patients >108lbs (49kg) who are not candidates for flexible IM nailing Piriformis or near-piriformis entry nailing is NOT a treatment option Risk of injury to the lateral ascending cervical branches of the medial femoral circumflex vessel in the piriformis fossa Increased risk of femoral head osteonecrosis (=4%) Risk of coxa vara due to trochanteric apophyseal growth arrest Permits rapid mobilization Dr. Routt: The use of intramedullary devices raises the question of implant size and intramedullary reaming. Someone asked earlier what is meant by "gentle reaming". As the patient's body size decreases, canal diameters decrease and you have an inventory problem. You may need a 9 mm diameter nail and you would like it to be a locking 9 mm diameter nail. When I first started at HarborView in 1988, we didn't have locking 9 mm nails. You had to go to the shop and drill the locking holes in the nail. Then you lost the manufacturers coverage of the implant but sometimes it was a matter of necessity. Now the manufactures have responded and there are much smaller diameter nails but you should check your hospital's inventory if you are planning on using some form of locking medullary implant. Although this treatment method requires an anaesthetic, it provides a much more stable fixation and obviates the need for a cast. In a growing child you would anticipate the need for implant removal and a major concern is aseptic necrosis of the femoral head. Bob Winquist and Dick Kirby (J Pediatr Orthop 1981;1(2):193-7) published a series on intramedullary nailing of adolescent femoral shaft fractures and had a zero percent incidence of aseptic necrosis. In the last couple of years case reports and now even some series have started to appear citing the appearance of aseptic necrosis of the femoral head. I think we can do things to avoid that. A, Intraoperative photograph of the proximal femur demonstrating the perforation of terminal subsynovial branches of the medial femoral circumflex artery (MFCA) into bone. These branches are located on the posterosuperior aspect of the femoral neck and penetrate the bone 2 to 4 mm lateral to the bone-cartilage junction. B, Schematic diagram showing the femoral head (1), gluteus medius (2), deep branch of the MFCA (3), terminal subsynovial branches of the MFCA (4), insertion of the gluteus medius tendon (5), piriformis tendon insertion (6), lesser trochanter with nutrient vessels (7), trochanteric branch (8), branch of the first perforating artery (9), and trochanteric branches (10). Dr. Routt: The use of intramedullary devices raises the question of implant size and intramedullary reaming. Someone asked earlier what is meant by "gentle reaming". As the patient's body size decreases, canal diameters decrease and you have an inventory problem. You may need a 9 mm diameter nail and you would like it to be a locking 9 mm diameter nail. When I first started at HarborView in 1988, we didn't have locking 9 mm nails. You had to go to the shop and drill the locking holes in the nail. Then you lost the manufacturers coverage of the implant but sometimes it was a matter of necessity. Now the manufactures have responded and there are much smaller diameter nails but you should check your hospital's inventory if you are planning on using some form of locking medullary implant. Although this treatment method requires an anaesthetic, it provides a much more stable fixation and obviates the need for a cast. In a growing child you would anticipate the need for implant removal and a major concern is aseptic necrosis of the femoral head. Bob Winquist and Dick Kirby (J Pediatr Orthop 1981;1(2):193-7) published a series on intramedullary nailing of adolescent femoral shaft fractures and had a zero percent incidence of aseptic necrosis. In the last couple of years case reports and now even some series have started to appear citing the appearance of aseptic necrosis of the femoral head. I think we can do things to avoid that. A, Intraoperative photograph of the proximal femur demonstrating the perforation of terminal subsynovial branches of the medial femoral circumflex artery (MFCA) into bone. These branches are located on the posterosuperior aspect of the femoral neck and penetrate the bone 2 to 4 mm lateral to the bone-cartilage junction. B, Schematic diagram showing the femoral head (1), gluteus medius (2), deep branch of the MFCA (3), terminal subsynovial branches of the MFCA (4), insertion of the gluteus medius tendon (5), piriformis tendon insertion (6), lesser trochanter with nutrient vessels (7), trochanteric branch (8), branch of the first perforating artery (9), and trochanteric branches (10).

20. Femoral Shaft Fractures: 11 years - Skeletal Maturity Femoral head osteonecrosis Dr. Routt: You can deal with the trochanteric apophyseal arrest and some of the proximal femoral angulatory deformities that might occur - but you don't have an effective way to deal with a dead femoral head in a child. This is a disaster. If you have never seen it before, there you have it. This is a case that was sent in to Dr. Winquist a long time ago on a child and you can see it had a medial starting point. If you are curious about this and you look in the literature and you look at the case reports of aseptic necrosis in adolescent femoral shaft fractures treated with medullary implants all of the starting points are quite medial. Try to avoid this injury to the femoral head blood supply.Dr. Routt: You can deal with the trochanteric apophyseal arrest and some of the proximal femoral angulatory deformities that might occur - but you don't have an effective way to deal with a dead femoral head in a child. This is a disaster. If you have never seen it before, there you have it. This is a case that was sent in to Dr. Winquist a long time ago on a child and you can see it had a medial starting point. If you are curious about this and you look in the literature and you look at the case reports of aseptic necrosis in adolescent femoral shaft fractures treated with medullary implants all of the starting points are quite medial. Try to avoid this injury to the femoral head blood supply.

21. Femoral Shaft Fractures: 11 years - Skeletal Maturity Rigid intramedullary nailing- lateral entry femoral nail Similar indications to trochanteric entry nails Designed to avoid injury to circumflex vessels and trochanteric apophysis

22. Pediatric Femoral Shaft Fractures Unable to recommend for/against removal of surgical implants from asymptomatic patients with healed diaphyseal femur fractures (AAOS Clinical Practice Guideline) Risks include refracture, hematoma, infection, scarring, etc. Regional anesthesia is an option for perioperative care (Hematoma and/or Femoral Nerve Block) - AAOS Clinical Practice Guideline Reduced narcotic administrated demonstrated with hematoma block

23. References Aksahin E, et. al. Immediate Incorporated Hip Spica Casting in Pediatric Femoral Fractures: Comparison of Efficacy Between Normal and High Risk Groups. Journal of Pediatric Orthopaedics 2009; 29(1): 39-43. Anglen JO, Choi L. Treatment Options in Pediatric Femoral Shaft Fractures. Journal of Orthopaedic Trauma 2005; 19(10): 724-733. Flynn HM, Luedtke LM, Ganley TJ, Dawson J, Davidson RS, Dormans JP, Ecker ML, Gregg JR, Horn BD, Drummond DS. Comparison of Titanium Elastic Nails With Traction and a Spica Cast to Treat Femoral Fractures in Children. J Bone & Joint Surg Am 2004; 86: 770-777. Flynn JM, Schwend RM. Management of Pediatric Femoral Fractures. JAAOS 2004; 12(5): 347-359. Garner MR, Bhat SB, Khujanazarov I, Flynn JM, Spiegel D. Fixation of Length-Stable Femoral Shaft Fractures in Heavier Children. Journal of Pediatric Orthopaedics 2011; 31(1): 11-16. Gautier E, Ganz K, Krugel N, Gill T, Ganz R. Anatomy of the Medial Femoral Circumflex Artery and Its Surgical Implications. J Bone & Joint Surg Br 2000; 82(5): 679-683. Hosalkar HS, Pandya NK, Cho RH, Glaser DA, Moor MA, Herman MJ. Intramedullary Nailing of Pediatric Femoral Shaft Fractures. JAAOS 2011; 19(8): 472-481. Mansour AA, Wilmoth JC, Mansour AS, Lovejoy SA, Mencio GA, Martus JE. Immediate Spica Casting of Pediatric Femoral Fractures in the Operating Room Versus the Emergency Department: Comparison of Reduction, Complications, and Hospital Charges. Journal of Pediatric Orthopaedics 2010; 30(8): 813-817. Kocher MS, Sink EL, Blasier RD, Luhmann SJ, Mehlman CT, Scher DM, Matheney T, Sanders JO, Watters WC, Goldberg MJ, Keith MW, Haralson RH, Turkelson CM, Wies JL, Sluka P, Hitchcock K. AAOS Clinical Practice Guideline Summary: Treatment of Pediatric Diaphyseal Femur Fractures. JAAOS 2009; 17: 718-725. Poolman RW, Kocher MS, Bhandari M. Pediatric Femoral Fractures: A Systematic Review of 2422 Cases. Journal of Orthopaedic Trauma 2006; 20(9): 648-654. Sagan ML, Datta JC, Olney BW, Lansford TJ, McIff TE. Residual Deformity After Treatment of Pediatric Femur Fractures With Flexible Titanium Nails. Journal of Pediatric Orthopaedics 2010; 30(7): 638-643.

24. References Sink EL, Faro F, Polousky J, Flynn K, Gralla J. Decreased Complications of Pediatric Femur Fractures With a Change in Management. Journal of Pediatric Orthopaedics 2010; 30(7): 633-637. Wright JG. The Treatment of Femoral Shaft Fractures in Children: A Systematic Overview and Critical Appraisal of the Literature. Canadian Journal of Surgery 2000; 43(3): 180-189.