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Plating of Femur Fractures in Children PDF Print E-mail

P. Christopher Cook, M.D., FRCSC
Halifax, NS

Plating is one option in a whole armamentarium of treatment modalities for fracture femurs in children, all of which can produce excellent results. Treatment should, therefore, be individualized, accounting for factors such as age, patient size, fracture pattern, location, associated injuries, social aspects and physician experience, ability and preference. 

Advantages of plating include anatomical reduction, ease of nursing care, rapid mobilization, no necessity for casting and rapid healing. Plate fixation has thus been recommended for those patients with head injury and multiple trauma where improved nursing and mobilization are particularly desirable. Further, fractures in the proximal or distal thirds of the femur may be more readily treated by plate fixation because of the more rigid fixation and greater ability to produce an anatomic reduction. Pathological fractures, especially in the proximal and distal femur, which create a large area of bone loss, may also be treated with plating to allow for earlier mobilization, prevention of deformity and to avoid cast immobilization. Plate fixation may also be used when other treatment modalities have failed. Indeed, in the adolescent age group where operative treatment is more often desirable, plate fixation may be used as the primary treatment modality.

Disadvantages include a long incision, risk of infection, femoral overgrowth, plate breakage and re-facture after removal. Overgrowth can occur in this setting and has been reported to be as much as an inch in children greater than ten years. This, however, is uncommon and it is usually not clinically significant. Care with dissection to decrease stripping and muscle damage may help in preventing or minimizing overgrowth. Plate breakage requiring reoperation, although rare, has been reported as a significant problem that should temper one’s decision to use plate fixation. Two factors have to be considered with respect to this issue in children. Firstly, comminution on the medial side has to be identified. This would then necessitate bone grafting and/or extra care with postoperative activity and weight-bearing. Secondly, one theory suggests that children may be predisposed to plate breakage owing to the less rigid more plastic mechanical characteristics of their bone. This would fatigue the plate as a result of the greater bending moment. It is true that most femurs plated in children heal with a lot of callous formation. It is this author’s belief that the plate size should be tailored to the size of the child’s femur so as to more readily allow this callous to form. A broad plate that is not too long with eight cortices for the larger child and proportional decrease in size for the smaller child is reasonable. Re-fracture after removal is a problem only if the plate is removed. This issue remains a matter of some controversy. Plates are removed to avoid incorporation into the femur of a younger child and fracture at the end of the plate in others. There have been reports of plates remaining in-situ in adolescents, who play contact sports, without sequelae.
Figure 1



Figure 1 is a case of a 13-year-old female, daughter of an orthopaedic surgeon, who had failed nonoperative treatment followed by plating of her fracture. X-rays three weeks later already show a large amount a callous formation medially. Owing to subsequent medical issues, the plate was not removed. Six years later she is asymptomatic and is active as a competitive skier and basketball player. This case illustrates how children’s fractures heal with plate fixation and highlights the controversies surrounding plate removal.

In summary, plating is becoming less frequently used owing to the popularity of less invasive operative techniques. Presently, plating is mainly used in children with head injury, multiple trauma and when other treatment modalities have failed. Use of bone graft, careful tissue dissection, caution with postoperative activity and weight-bearing and use of appropriate size plates will help minimize potential complications. The advent of extraperiosteal plating systems and their ability to be applied percutaneously may, in the future, have implications for indications and popularity of plating femoral fractures in children.