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Complications of Pediatric Femoral Shaft and Distal Physeal Fractures

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Complications of Pediatric Femoral Shaft and Distal Physeal Fractures 40 Complications of Pediatric Femoral Shaft and Distal Physeal Fractures William P. Bassett, BA Shannon Safi er, MD Martin J. Herman, MD Scott H. Kozin, MD Joshua M. Abzug, MD Abstract Fractures of the femoral shaft comprise about 1.6% of all bony injuries in children and are the most common pediatric orthopaedic injury that requires hospitalization. The treatment of femoral fractures in children is largely dependent on the child’s age and size and takes into account multiple considerations: the child’s weight, associated injuries, the fracture pattern, the mechanism of injury, institutional or surgeons’ preferences, and economic and social concerns. In addition, during the past two decades, there has been a dramatic change favoring surgical fi xation rather than casting because of the many advantages of fi xation, including more rapid mobilization. The goal of treatment should be to ultimately obtain a healed fracture and avoid associated complications, such as nonunion or delayed union, angular or rotational deformity, unequal limb lengths, infection, neurovascular injury, disruption of the growth plate, muscle weakness, and/or compartment syndrome. Instr Course Lect 2015;64:461–470. Fractures of the femur are common in- for these fractures include a healed frac- injuries in children and are the most juries in pediatric patients. This chapter ture and avoiding complications. common pediatric orthopaedic injury discusses fractures of the femoral shaft that requires hospitalization. Femoral and distal femoral physis. At these lo- Femoral Shaft Fractures shaft fractures in children are more cations, there is a substantial risk for Fractures of the femoral shaft com- common in boys and follow a bi modal complications. The goals of treatment prise approximately 1.6% of all bony age distribution, with the fi rst peak oc- curring during the toddler years and a Dr. Safi er or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf second peak in adolescence. Toddlers of Orthopediatrics and serves as a paid consultant to or is an employee of Orthopediatrics and Medicrea. Dr. Herman or an immediate family member serves as a board member, owner, offi cer, or committee member of the American Academy and young children are most com- of Orthopaedic Surgeons and the Pediatric Orthopaedic Society of North America. Dr. Kozin or an immediate family monly injured from simple falls, such member serves as a paid consultant to or is an employee of Checkpoint Surgical and serves as a board member, owner, offi cer, as tripping while running or a fall from or committee member of the American Society for Surgery of the Hand. Dr. Abzug or an immediate family member serves as a paid consultant to or is an employee of Axogen. Neither Mr. Bassett nor any immediate family member has received a low height. Older children and adoles- anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly cents sustain fractures most commonly to the subject of this chapter. from higher-energy injuries, with nearly © 2015 AAOS Instructional Course Lectures, Volume 64 461 Pediatrics 90% of the femoral fractures in older including osteogenesis imperfecta; dis- Orthopaedic Surgeons’ guideline for children resulting from motor vehicle use osteopenia in children with neuro- the treatment of pediatric diaphyseal crashes.1,2 muscular disease, such as cerebral palsy; femoral fractures is, in the opinion of Child abuse is another etiology of myelomeningocele; and neoplasms.1,2 this chapter’s authors, a good algorithm femoral fractures. Battered children of- for treating most patients.7 ten present fi rst with a fracture, and it Treatment Options is estimated that orthopaedic surgeons The treatment of femoral fractures Goals of Treatment see 30% to 50% of abused children. in children is largely dependent on a The goals of treatment should be to Consequently, orthopaedic surgeons are child’s age and size. Any treatment ultimately obtain a healed fracture and often responsible for distinguishing in- decision, however, involves multiple avoid associated complications, such tentional from unintentional injuries in considerations: the child’s weight, as- as nonunion or delayed union, angu- young children. Up to 60% of fractures sociated injuries, the fracture pattern, lar or rotational deformity, unequal seen in child abuse are isolated injuries, the mechanism of injury, institutional leg lengths, infection, neurovascular and the most common bone fractures or surgeons’ preferences, and economic injury, disruption of the growth plate, are of the femur and the humerus. and social concerns.4,6 Although fem- muscle weakness, and/or compartment Long-bone diaphyseal fractures are the oral diaphyseal fractures can create syndrome.1,2,4 Each primary treatment most common fracture patterns seen in substantial short-term disability, these modality has associated complications intentional injuries.1,2 These fractures injuries can be successfully treated with that will be discussed in detail. are seen at least as often as the typical a variety of interventions. The scien- epiphyseal-metaphyseal fractures (cor- tifi c literature provides little evidence Spica Casting ner or bucket-handle fractures) that are in terms of supporting one method of The current standard of care for young thought to be more pathognomonic treatment over another because the out- children aged 6 months to 6 years with of abuse.1-4 Before walking age, up to comes in this population are believed an isolated femoral diaphyseal fracture 80% of femoral shaft fractures may be to be good if an accepted method of is the application of an immediate hip caused by abuse. In a study by Coffey treatment is executed effectively.6 In spica cast within 24 to 48 hours. Ear- et al5 of more than 5,000 children at the past, the standard of care for most ly spica casting is ideally indicated for a trauma center, only 1% of the lower pediatric diaphyseal femoral fractures femoral shaft fractures, with as much as extremity fractures in children older was either casting or traction followed 20 mm of initial shortening. The cast than 18 months were caused by abuse, by casting. In the modern era, however, is generally worn for a period of 4 to whereas child abuse was the direct casting is used primarily for younger 8 weeks. The advantages of an imme- cause in 67% of the fractures in chil- children who have a substantial capacity diate spica cast include relatively low dren younger than 18 months. Other to undergo remodeling.4 cost, low complication rates, and a very investigators have reported that 65% The change in care plans for chil- high rate of achieving union with prop- of the femoral fractures occurring in dren and adolescents away from casting er alignment.1,2,8,9 infants younger than 1 year were caused toward fi xation has occurred during the However, the primary disadvantage by abuse, with a much lower incidence past two decades. Pediatric orthopae- of the immediate spica cast relates to of 35% in children aged 1 to 5 years.3 dists have become familiar with pe- the challenges of caring for the af- In younger children, it also is impor- diatric intramedullary nail techniques fected child. Families have reported tant to consider fractures that occur and increasingly have recognized the substantial restrictions on mobility as a result of the failure of pathologic advantages of fi xation and rapid mo- because most children are completely bone caused by minimal trauma. Al- bilization. Furthermore, early surgical dependent, requiring the use of wagons though rare, this should be suspected treatment of a child with high-energy or wheelchairs. This decrease in mo- in younger children with multiple frac- trauma, a head injury, or associated bility further affects a child’s presence tures. Several common conditions can multiple trauma may reduce compli- in school and can cause a substantial result in weakened bone and, therefore, cations and decrease the overall hos- loss of the parents’ time from work to lead to a predisposition to fracture, pital stay.4 The American Academy of care for the child.8,10 The social costs of 462 © 2015 AAOS Instructional Course Lectures, Volume 64 Complications of Pediatric Femoral Shaft and Distal Physeal Fractures Chapter 40 this treatment method have been deter- the fracture into a valgus position to mined to be greatest when the child is help counter the natural tendency of a of school age (older than 5 years) and more varus position that occurs during both parents work.1,2 healing because of the unopposed thigh adductors.8 This position also facilitates Technique hip carrying of the child, eases toilet- Two types of spica casting are common- ing, and allows school-age children to ly used. They differ based on the length attend class in a reclining wheelchair.1,2 of the cast placed on the unaffected A single-leg spica cast is positioned with limb, thereby allowing distinctive de- approximately 30° of hip and knee fl ex- grees of mobility while maintaining ion, leaving the foot positioned such Figure 1 Spica casting options. A, Unilateral hip spica cast. reduction (Figure 1). Excellent results that the child may toe-touch on the B, One and one-half hip spica cast. have been reported using both the fractured side to improve walking sta- C, Bilateral long leg hip spica cast. unilateral (single leg) hip spica cast and bility.1,2,8 Obtaining excessive traction (Courtesy of Lucile Packard Chil- dren’s Hospital, Palo Alto, CA.) the one and one-half hip spica cast.8 by grasping the calf or the foot of the Currently, there is an increasing interest fractured side or by pulling through in using the more patient-friendly, uni- a short leg cast is not recommended Complications of Spica Treatment lateral hip spica cast.
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