ORTHOPEDICS: EDITED BY DANIEL W.

GREEN

Femoral fractures in children

Brousil, James; Hunter, James B.
Author Information
Current Opinion in Pediatrics: February 2013 - Volume 25 - Issue 1 - p 52-57
doi: 10.1097/MOP.0b013e32835c20e0

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Abstract
Purpose of review 

Femoral fractures in children are the commonest children's fracture requiring hospitalization.
They consume disproportionate amounts of healthcare resource. Advances in operative
management have resulted in improved clinical and health economic outcomes.

Recent findings 

This article describes 21st-century management of femoral fractures concentrating on recent

advances. There is a clear trend to increased operative management in all femoral fractures
with improved outcomes in the proximal femur and shaft. Crucially, advances in the
treatment of both have led to a reduction in the rate of avascular necrosis of the femoral head.

Summary 

Units treating paediatric fractures need access to specialist surgeons and equipment to treat
the full range of femoral fractures and improve outcomes.

INTRODUCTION
Fractures of the femoral shaft in children are the second most common diaphyseal fracture
seen in children, after those of the forearm [1]. They are the most common musculoskeletal
injury in children requiring hospitalization [2]. These injuries have an annual incidence of
between 16.5 and 28 per 100 000 children per year [3▪]. The cause of these injuries varies with
age; in preschool children the most common mechanism is a fall from a height of less than 1
m. In children aged 4–12 years accidental injury during sport is the predominant cause. In
older children and the adolescent road traffic accidents are the predominant cause [3▪]. The
method of management of these injuries varies with age and weight of the child, although
local cultural and socioeconomic factors also play a major role [3▪,4]. Controversies still persist
over the safety of locked anterograde intramedullary nailing and the use of elastic nails in
length unstable diaphyseal fractures.

FRACTURES OF THE PROXIMAL FEMUR

Fractures to the proximal femur are rare and represent fewer than 1% of all paediatric
fractures. They are usually high-energy injuries and may present as part of the injury pattern
of the polytraumatized patient. Children commonly sustain these injuries as a result of a fall
from height or as a pedestrian in a motor vehicle accident.

CLASSIFICATION
These injuries are traditionally classified using the Delbet's system, popularized by
Colonna [5], which typifies these injuries (see Table 1).

Table 1: 
Delbet's classification and its relation to AVN rates posthip fracture

MANAGEMENT
There is an increasing trend towards stable internal fixation for these injuries, with implants
of a suitable size for the child in question. Nonunion and malunion are prevented by the use
of modern angular stable implants.

PROGNOSIS
Each fracture pattern carries a chance of risk of avascular necrosis (AVN) and subsequent
posttraumatic arthritis. This risk increases with the proximity of the fracture (see Table 1) and
with the age of the child. Moon demonstrated this risk increases 1.14 times with each year of
age [6]; several case series suggest the risk is greatest in children older than 10 [7].

Box 1: 
no caption available

Initial displacement of the fracture and subsequent delay to reduction are also contributory to
AVN development. Results for fractures reduced and fixed emergently are significantly better
than those delayed beyond this time frame. Flynn et al.[8] demonstrated an 8% AVN rate in his
series all fixed within 24 h; this jumps to 60% in Dhar's series, in which the median delay to
surgery was 8 days [9▪].

Some recent studies have shown open rather than closed reduction, followed by internal
fixation, results in a lower incidence of AVN [10,11▪,12]. This relates both to the quality of the
reduction achieved prior to fixation, and to the fact that open reduction necessitates
decompression of the tamponading haematoma in the hip joint. The conclusion drawn from
these comparable, albeit small, case series is that anatomical reduction reduces the risk of
development of AVN.

FRACTURES OF THE FEMORAL SHAFT

The following discussion is organized and divided using age as the primary denominator.

Infants 0–18 months old

Fractures in this early age group must arouse suspicion in the treating clinician and the
possibility of nonaccidental injury (NAI) excluded. The child is nonambulatory for much of
the first year of life; hence the application of an external force is a more likely aetiology in
this group. Eighty percent of all abusive fractures occur in this age group, yielding an
incidence of four in every 100 000 children under 18 months of age [13]. The incidence of these
fractures caused by NAI is seen to decrease with age, in keeping with the onset of ambulation
and growth of the child. The presence of synchronous fractures (especially to the ribs),
evidence of previous abusive injury (physical or radiological) and a history/presentation
which raises suspicion are also strong indicators of NAI [14,15]. Paediatricians should be aware
that, although NAI is common, a regular traumatic cause is more common.

MANAGEMENT
Options include traction or hip spica casting, or a combination of both. We recommend
gallows traction for small children (i.e. <12 kg), which involves inline skin traction with the
hip flexed at 90°. The application of traction mandates hospital admission and allows
thorough investigation of the circumstances of the injury in a controlled environment. Use of
this technique in larger children is to be avoided as it has been associated with compartment
syndrome, volkmanns contracture and peroneal nerve palsy.

Immediate hip spica casting is an acceptable form of treatment with proven results [16].
Femoral fractures in this age group very rarely suffer from the shortening seen in older
children treated with this method. Its application requires the availability of a paediatric
anaesthetist. Given the emergent presentation of many of these injuries, this service is not
always immediately available. In resource limited environments spica casting is applied after
a brief period in traction (1 week or so) and can often be achieved without anaesthesia [17]. Up
to 15 mm of shortening and 30° of angulation are considered acceptable, given the
considerable remodelling potential at this age [16]. Rotational deformity, although rare, does
not remodel.

Fractures of the femur during birth are rare and often discovered latently. The newborn can
be immobilized in a Pavlik harness for up to 3 weeks. Rapid callus formation is typically
observed with little in the way of long-term sequelae. Risk factors for these injuries include
breech deliveries, twin pregnancies and osteoporosis of birth related to prematurity or
maternal neurological conditions which reduce intrauterine movements (i.e. spina bifida) [18].

TREATMENT OF CHILDREN AGED 18 MONTHS TO 4

YEARS
In this ambulant age group the most common cause is a simple fall. Hence these are often
isolated, low energy injuries. Nonaccidental injury becomes much less common, representing
one in 205 fractures in this age group compared with one in nine below the age of 18
months [13].

Traction or hip spica is the mainstay of treatment. We prefer balanced Hamilton–Russell skin
traction applied with 1 pound of weight per year of age, as it has the benefit of controlling
both external rotation and shortening.

Hip spica casting may be used either immediately or subsequent to initial traction. Immediate
application is said to reduce treatment costs, but has been associated with subsequent
malunion [18–20], especially in length unstable fractures. These fractures benefit from a brief
period of balanced traction before definitive management with spica casting. Shortening of
more than 15 mm, if appreciated in the early follow-up period, is an indication for resumption
or initiation of traction methods. Angulation of up to 15° of varus/valgus and 25° in the
sagittal plane can be tolerated [21].

CHILDREN AGED 4–12 YEARS

In these older children operative intervention is increasingly indicated.

Traction

This may still be used, usually as a temporizing measure prior to operative intervention.
Comparative studies between skin and skeletal traction have shown little benefit of one
modality over another, especially in the young children [22]. Skeletal traction should be
avoided, especially in the proximal tibia, due to the risk of growth arrest.

Hip spica

Hip spica management in the over-4s is not appropriate. Wright et al.'s[23] randomized

controlled trial (a rarity in paediatric orthopaedics) demonstrated that external fixation was
better, although not without its own complications.

Elastic nailing

This is now the technique of choice for stabilizing femoral fractures in children of this age
group. Superior results to spica casting have been demonstrated in terms of length of hospital
stay, time to mobilization and patient satisfaction [24].

Elastic nails act both as a reduction device and secondarily as an implant. They may be
applied to most femoral fractures including length unstable injuries if appropriate precautions
are undertaken.

LIMITATIONS OF ELASTIC NAILING

Poor outcomes in terms of loss of alignment and delayed union have been described in larger
children, that is, over 49 kg, and in those fractures which have gross comminution [25]. There is
also a reported increased risk of shortening and malunion in length unstable fractures
compared with stable configurations treated with this technique [26,27].

For fractures that tend towards axial instability, the use of an end cap should be considered.
This device is placed over the protruding nail end and its screw thread grips in the cortex. It is
intended to prevent extrusion of the nail and controls shortening of the fracture. Ex-vivo
biomechanical studies have shown this technique to be effective and a clinical case series has
shown these devices to be safe and of benefit [28▪].

Distal third femoral fractures may also be addressed with this technique, using an antegrade
insertional technique. This requires two proximal start points, the first 1 cm proximal and just
anterior to the second. Two nails are again used, the first C shaped and the second S shaped.
This allows two apical curves to rest at the same level via two lateral entry points, but does
represent a greater technical challenge [29].

Postoperatively immediate mobilization occurs with protected weight bearing for the first 2–3
weeks. No brace or cast is routinely used unless special circumstances require this.
Metalwork removal is generally performed at 6 months postoperatively.

EXTERNAL FIXATION
External fixators have been used to manage comminuted fractures with associated severe soft
tissue injuries since the 1970 s. Historically this technique has been associated with delayed
union, refracture, malalignment and pin site infection [30–32]. Fractures treated by external
fixation heal slowly, such that devices have to remain in situ for up to 12 weeks to reduce
refracture rates to an acceptable level [30]. Late dynamization seems to be of little benefit to
stimulate healing; hence the recommendation is to use less rigid frame constructs from the
outset to allow early callus formation [33].

For adult open fractures the trend is away from external fixation in favour of primary
intramedullary nailing with synchronous extensive soft tissue debridement and grafting.
Randomized comparative studies in the paediatric population comparing external fixation
with intramedullary nailing are awaited, but cohort studies do exist [34]. This small
retrospective study compared a combination of elastic and rigid nailing with external fixators
and found that the ex fix group were 2.7 times more likely to have a complication (refracture,
delayed or malunion and limb length discrepancy). Despite the shift in practice, the external
fixator retains a place in the management of the polytraumatized child due to its speed and
simplicity of application.

PLATE FIXATION
Rarely required in this age group except for very proximal fractures beyond the scope of
elastic nails.

OLDER CHILDREN AND ADOLESCENTS

In this group operative management is nearly always indicated.
ELASTIC NAILING
This is technically feasible; however, the work of Moroz et al.[25] showed the incidence of
radiographic malunion increases five-fold if performed in children weighing more than 49 kg.
It should be pointed out that this statement arises from a study which did not include fracture
type as a variable; hence there are accounts of elastic nailing used in the older child
(weighing up to 85 kg) in selected cases of ‘length stable’ fractures. Comparative studies
have shown no difference in outcome in these cases compared with locked rigid
intramedullary nailing [35]. If elastic nailing is undertaken, augmentation with femoral brace or
a brief period of bed rest should be considered. Some authors have advocated augmentation
of the construct with a temporary external fixator to provide added axial stability. End caps
increase the strength of the construct six-fold [28▪].

PLATE FIXATION
Plate fixation provides another treatment option for femoral fractures in the older child and
adolescent. This has been performed historically with good results reported [36]. This approach
conventionally requires a substantial approach and soft tissue dissection; a substantial scar
must also be expected, which can be a problem in some children.

The introduction of locked plates has broadened the indications for plating and offers a ready
alternative treatment option to the external fixator in the treatment of closed, grossly
comminuted fractures [37]. The locked plate has been likened to an ‘internal external fixator’
and hence may be used to bridge across comminuted fractures or stabilize those at the
metaphyseal/diaphyseal junction, wherein the space available to achieve distal fixation is
limited. The locked plate may also have a role to stabilize fractures within pathological bone,
for example osteopenia or osteogenesis imperfecta.

Disadvantages include difficulty in obtaining adequate reduction prior to plating, especially if

minimally invasive plating is attempted. The locked plate is also not designed for load
sharing. Hence, if it is repetitively loaded prior to bone healing there is a chance of implant
failure.

LOCKED ANTEGRADE INTRAMEDULLARY NAILING

This is the gold standard treatment for femoral fractures in the adult population. Its use in
children has been restricted due to concerns over avascular necrosis of the femoral head and
growth arrest in the proximal femur secondary to operative technique. In the series that do
exist, there can be little doubt as to the efficacy of intramedullary nailing in treating
diaphyseal fractures of the paediatric femur [38]. The indications for this technique are
increasing due to the trend towards heavier patients in the paediatric population.

The main concern arises from the entry point of the nail, which historically was the piriform
fossa. Until skeletal maturity the blood supply of the femoral head depends almost entirely on
the lateral ascending cervical artery, arising from the ascending branch of the medial femoral
circumflex artery. This passes in close proximity to the piriformis fossa and hence is at risk
from nail insertion using this at the start point.
To avoid this devastating, untreatable complication some authors have advocated a
trochanteric entry point (TEP) [39,40]; this has been associated with growth arrest of the
proximal femur resulting in valgus deformity of the hip and narrowing of the femoral neck
and metaphysis [41,42]. This would suggest that the medial wall of the trochanter must be
preserved to avoid damage to the proximal femoral vasculature. To this end a lateral
trochanteric entry point (LEP) has been described to allow insertion of modified humeral
nails [43▪], novel flexible interlocking intermedullary nails [44,45▪] and specifically designed
adolescent nails [46▪▪].

The true incidence of AVN after this procedure is unknown but a recent review of published
case series describes the data from 19 retrospective studies, containing cases using all three
techniques [45▪]. The coalition of these cases revealed a 2% AVN rate in the piriformis fossa
entry point group (N = 239), a 1.4% AVN rate in the TEP case (N = 139) and no cases of
AVN in the LEP group (N = 80). Six further case reports of AVN subsequent to
intramedullary nailing are described in the literature, all using the piriformis fossa entry point
technique. Although this data is all from nonrandomized, retrospective studies in nonmatched
populations, the logical suggestion is, however, that a lateral entry point is safer for this
technique.

FRACTURES OF THE DISTAL FEMUR

Growth plate fractures of the distal femur are rare injuries and carry a high rate of
complication. Primary among these is growth arrest, the rate of which has been stated as
between 40 and 52% [47]. This increases with the grade of the fracture, degree of displacement
and presence of proximal fragment comminution [48]. The Salter–Harris classification is used.

SALTER–HARRIS I INJURIES
Undisplaced injuries may be placed in a cast, nonweight bearing for 4 weeks. Displaced
injuries deemed unstable enough to warrant internal fixation should undergo closed
manipulation followed by anterograde crossed K wiring. These wires are left proud of the
skin and should cross the physis to ensure solid fixation. Entry points should be parallel and
proximal to the joint capsule to the knee. The leg is cast as above and wires are removed with
the cast at 4 weeks.

SALTER–HARRIS II INJURIES
These are often seen resulting from sporting injuries. Some authors advocate fixing all SH II
fractures regardless of initial displacement [48]. If managed conservatively, regular radiographs
are required. Operative intervention depends on the size of the metaphyseal fragment. If large
enough, the fracture may be held with one or two screws placed perpendicular to the
fragment's surface into the metaphysis. Orientation of this screw is vital to achieving solid
fixation and operative planning may be aided by computed tomography (CT) scanning or
oblique radiographs. Crossed wires may be used if the fragment is too small for screw
fixation.

SALTER–HARRIS III AND IV INJURIES

These injuries are transphyseal intraarticular fractures and should be operatively stabilized.
CT is useful for operative planning. Open reduction and internal fixation are required.
Malreduced fractures will lead to rapid onset posttraumatic arthritis.

CONCLUSION
Methods of management vary depending on anatomical location of fracture, age of patient
and associated injuries. Units treating paediatric fractures need access to specialist surgeons
and equipment to treat the full range of femoral fractures and improve outcomes. Further
randomized controlled trials are needed to determine optimal treatment modalities for some
fractures of the femoral shaft.

Acknowledgements
None.

Conflicts of interest

There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been
highlighted as:

 ▪ of special interest
 ▪▪ of outstanding interest

Additional references related to this topic can also be found in the Current World Literature
section in this issue (p. 151).