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External Fixation of Paediatric Femoral Fractures PDF Print E-mail

James G. Wright, M.D., MPH, FRCSC
Toronto, ON

The treatment of femur fractures in children is controversial and highly variable.1 Each method of treatment has practical and theoretical advantages and disadvantages. The literature provides few comparative studies.2 Malunion is the most frequently used endpoint of treatment but every treatment is prone to different types of malunion. Any evaluation of treatment must consider all aspects of malunion including displacement, angulation, rotation, and length.  

Traction is probably the most common treatment for paediatric femoral fractures worldwide. The disadvantages of traction, in addition to the cost and potential behavioral consequences of prolonged hospitalization, include rotary malunion and over-lengthening. Early application of hip spica obviates prolonged hospitalization but is burdensome for families and has the potential for angulatory malunion and shortening. External fixation has low rates of malunion, but has the disadvantages of pin tract infection and re-fracture. Flexible nails also result in low rates of malunion but are more invasive and may require a second procedure for nail removal. Reamed intramedullary nailing, with probably the lowest rates of malunion, has the rare but devastating complication of avascular necrosis. Thus, the preferred treatment for paediatric femoral fracture is unknown.

When considering treatment for femoral fractures, in addition to family concerns, two important issues are patient age and whether the fracture is complicated or uncomplicated. Under four years, most surgeons would advise traction or hip spica. After age ten, most surgeons would recommend operative fixation. Operative fixation is also appropriate for children with complicated fractures, such as those with head injury, multiple injuries, floating knee, and open fractures. Fracture pattern can also affect treatment choices. External fixation is probably best when the fracture has more than 50% comminution or when the fracture is in the proximal or distal femur with a long oblique or spiral pattern. In these fractures, flexible nails may allow shortening and angulation.3

Figure 1
If external fixation is chosen, several aspects of the technique are important. First, although external fixation can be used for fractures throughout almost the entire length of the femur, for distal fractures a transverse pin cluster may be necessary, and for proximal fractures two pins must be placed close together at the level of the lesser trochanter (Figure 1). Second, when placing the frame, flexion of the proximal fracture must be avoided. (Fixation of the fracture in flexion leads to slow callous formation, posing significant risk of re-fracture.) Third, the fixator length needs to be preoperatively planned but can be placed on children as young as four years. Fourth, although dynamization probably has no advantage in speeding fracture healing4, children should be allowed to walk with weight-bearing as tolerated. Fifth, the care of the pin-tracts is controversial but we use once (or twice) daily hibitane cleansing with daily showers, and a five-day course of antibiotics for early pin-tract infections. Finally, we remove the fixator when bridging callous is seen on three of four cortices. We remove the fixators in the clinic.

Knowing which method is the preferred treatment for children, four to eleven years of age, with uncomplicated paediatric femoral fractures will await the results of randomized clinical trials. Such trials will require a full appraisal of malunion, assessment of child function, consideration of family satisfaction, and cost. We will be presenting the results of an international randomized trial comparing early application of hip spica with external fixation at the Annual POSNA Meeting in May 2003.

References

  1. Sanders J.O., Browne R.H., Mooney J.F., et al. Treatment of femoral fractures in children by paediatric orthopaedists: results of a 1998 survey. J Pediatr Orthoped 2001; 21:436-441.

  2. Wright J.G. The treatment of femoral shaft fractures in children: A systematic overview and critical appraisal of the literature. Can J Surg 2000; 43:180-189.

  3. Narayanan U.G., Hyman J., Rang M., Alman B.A. Complications of flexible intramedullary nailing of paediatric femur fractures and their prevention. Paediatric Orthopaedic Society of North America, Vancouver, BC, May 2000.

  4. Domb B.G., Sponseller P.D., Ain M., Miller N.H. Comparison of dynamic versus static external fixation for paediatric femur fractures. J Pediatr Orthoped 2002; 22:428-430.