Strategies in Trauma and Limb Reconstruction

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VOLUME 11 , ISSUE 2 ( August, 2016 ) > List of Articles


The management of paediatric diaphyseal femoral fractures: a modern approach

Al-achraf Khoriati, Carl Jones, Yael Gelfer, Alex Trompeter

Keywords : Paediatric, Femur, Fracture, Management, Review, Trauma, Evidence

Citation Information : Khoriati A, Jones C, Gelfer Y, Trompeter A. The management of paediatric diaphyseal femoral fractures: a modern approach. 2016; 11 (2):87-97.

DOI: 10.1007/s11751-016-0258-2

License: CC BY-NC-SA 4.0

Published Online: 01-06-2014

Copyright Statement:  Copyright © 2016; The Author(s).


The definitive treatment of paediatric femoral diaphyseal fractures remains controversial. Modalities of treatment vary mostly according to age, with fracture pattern and site having a lesser impact. Current evidence is reflective of this variation with most evidence cited by the American Academy of Orthopedic Surgeons being level 4 or 5. The authors present a review of the most up-to-date evidence relating to the treatment of these fractures in each age group. In an attempt to clarify the current trends, we have produced an algorithm for decision-making based on the experience from our own tertiary referral level 1 major trauma centre.

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  1. Bridgman S, Wilson R (2004) Epidemiology of femoral fractures in children in the West Midlands region of England 1991-2001. J Bone Joint Surg Br 86(8):1152-1157
  2. Harvey AR, Bowyer GW, Clarke NMP (2002) The management of paediatric femoral shaft fractures. Curr Orthop 16(4):293-299
  3. Schwend RM, Werth C, Johnston A (2000) Femur shaft fractures in toddlers and young children: rarely from child abuse. J Pediatr Orthop 20(4):475-481
  4. Pierce MC, Bertocci GE, Janosky JE, Aguel F, Deemer E, Moreland M et al (2005) Femur fractures resulting from stair falls among children: an injury plausibility model. Pediatrics 115(6):1712-1722
  5. Wallace ME, Hoffman EB (1992) Remodelling of angular deformity after femoral shaft fractures in children. J Bone Joint Surg Br 74(5):765-769
  6. Davids JR (1994) Rotational deformity and remodeling after fracture of the femur in children. Clin Orthop Relat Res 302:27-35
  7. Hunter JB (2005) Femoral shaft fractures in children. Injury. 36(Suppl 1):A86-A93
  8. Kasser JR (1992) Femur fractures in children. Instr Course Lect 41:403-408
  9. Ortiz EJ, Isler MH, Navia JE, Canosa R (2005) Pathologic fractures in children. Clin Orthop Relat Res 432:116-126
  10. Dameron TB Jr, Thompson HA (1959) Femoral-shaft fractures in children. Treatment by closed reduction and double spica cast immobilization. J Bone Joint Surg Am 41A:1201-1212
  11. Slongo TF (2005) The choice of treatment according to the type and location of the fracture and the age of the child. Injury 36(Suppl 1):A12-A19
  12. Slongo T, Audigé L, Hunter JB, Berger SM (2011) Clinical evaluation of end caps in elastic stable intramedullary nailing of femoral and tibial shaft fractures in children. Eur J Trauma Emerg Surg 37(3):305-312
  13. Morris S, Cassidy N, Stephens M, McCormack D, McManus F (2002) Birth-associated femoral fractures: incidence and outcome. J Pediatr Orthop 22(1):27-30
  14. Brousil J, Hunter JB (2013) Femoral fractures in children. Curr Opin Pediatr 25(1):52-57
  15. Cassinelli EH, Young B, Vogt M, Pierce MC, Deeney VF (2005) Spica cast application in the emergency room for select pediatric femur fractures. J Orthop Trauma 19(10):709-716
  16. Kemp AM, Dunstan F, Harrison S, Morris S, Mann M, Rolfe K et al (2008) Patterns of skeletal fractures in child abuse: systematic review. BMJ 337:a1518
  17. Sutcliffe JR, Wilson-Storey D, Mackinlay GA (1995) Children's femoral fractures: the Edinburgh experience. J R Coll Surg Edinb 40(6):411-415
  18. Dwyer AJ, Mam MK, John B, Gosselin RA (2003) Femoral shaft fractures in children-a comparison of treatment. Int Orthop 27(3):141-144
  19. Aksahin E, Celebi L, Yuksel HY, Hapa O, Muratli HH, Aktekin CN et al (2009) Immediate incorporated hip spica casting in pediatric femoral fractures: comparison of efficacy between normal and high-risk groups. J Pediatr Orthop 29(1):39-43
  20. Mansour AA 3rd, Wilmoth JC, Mansour AS, Lovejoy SA, Mencio GA, Martus JE (2010) Immediate spica casting of pediatric femoral fractures in the operating room versus the emergency department: comparison of reduction, complications, and hospital charges. J Pediatr Orthop 30(8):813-817
  21. (1990) Fractures and dislocations. WB Saunders, Philadelphia
  22. Vanlaningham CJ, Schaller TM, Wise C (2009) Skeletal versus skin traction before definitive management of pediatric femur fractures: a comparison of patient narcotic requirements. J Pediatr Orthop 29(6):609-611
  23. Martinez AG, Carroll NC, Sarwark JF, Dias LS, Kelikian AS, Sisson GA Jr (1991) Femoral shaft fractures in children treated with early spica cast. J Pediatr Orthop 11(6):712-716
  24. Beaty JH (2005) Operative treatment of femoral shaft fractures in children and adolescents. Clin Orthop Relat Res 434:114-122
  25. Kregor PJ, Song KM, Routt ML Jr, Sangeorzan BJ, Liddell RM, Hansen ST Jr (1993) Plate fixation of femoral shaft fractures in multiply injured children. J Bone Joint Surg Am 75(12):1774-1780
  26. Ward WT, Levy J, Kaye A (1992) Compression plating for child and adolescent femur fractures. J Pediatr Orthop 12(5):626-632
  27. Claes L, Heitemeyer U, Krischak G, Braun H, Hierholzer G (1999) Fixation technique influences osteogenesis of comminuted fractures. Clin Orthop Relat Res 365:221-229
  28. Kanlic EM, Anglen JO, Smith DG, Morgan SJ, Pesantez RF (2004) Advantages of submuscular bridge plating for complex pediatric femur fractures. Clin Orthop Relat Res 426:244-251
  29. Clement DA, Colton CL (1986) Overgrowth of the femur after fracture in childhood. An increased effect in boys. J Bone Joint Surg Br 68(4):534-536
  30. Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J (2001) Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop 21(1):4-8
  31. Flynn JM, Schwend RM (2004) Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 12(5):347-359
  32. Ligier JN, Metaizeau JP, Prevot J, Lascombes P (1988) Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 70(1):74-77
  33. Lee SS, Mahar AT, Newton PO (2001) Ender nail fixation of pediatric femur fractures: a biomechanical analysis. J Pediatr Orthop 21(4):442-445
  34. Moroz LA, Launay F, Kocher MS, Newton PO, Frick SL, Sponseller PD et al (2006) Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. J Bone Joint Surg Br 88(10):1361-1366
  35. Narayanan UG, Hyman JE, Wainwright AM, Rang M, Alman BA (2004) Complications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid them. J Pediatr Orthop 24(4):363-369
  36. Sink EL, Gralla J, Repine M (2005) Complications of pediatric femur fractures treated with titanium elastic nails: a comparison of fracture types. J Pediatr Orthop 25(5):577-580
  37. Flynn JM, Luedtke L, Ganley TJ, Pill SG (2002) Titanium elastic nails for pediatric femur fractures: lessons from the learning curve. Am J Orthop (Belle Mead NJ). 31(2):71-74
  38. Blasier RD, Aronson J, Tursky EA (1997) External fixation of pediatric femur fractures. J Pediatr Orthop 17(3):342-346
  39. Evanoff M, Strong ML, MacIntosh R (1993) External fixation maintained until fracture consolidation in the skeletally immature. J Pediatr Orthop 13(1):98-101
  40. Shih HN, Chen LM, Lee ZL, Shih CH (1989) Treatment of femoral shaft fractures with the Hoffmann external fixator in prepuberty. J Trauma 29(4):498-501
  41. Hedin H, Hjorth K, Rehnberg L, Larsson S (2003) External fixation of displaced femoral shaft fractures in children: a consecutive study of 98 fractures. J Orthop Trauma 17(4):250-256
  42. Hull JB, Sanderson PL, Rickman M, Bell MJ, Saleh M (1997) External fixation of children's fractures: use of the Orthofix Dynamic Axial Fixator. J Pediatr Orthop B 6(3):203-206
  43. Herring J (ed) (2003) Tachdjian‘s pediatric orthopaedics, 3rd edn. WB Saunders, Philadelphia
  44. Miner T, Carroll KL (2000) Outcomes of external fixation of pediatric femoral shaft fractures. J Pediatr Orthop 20(3):405-410
  45. Garner MR, Bhat SB, Khujanazarov I, Flynn JM, Spiegel D (2011) Fixation of length-stable femoral shaft fractures in heavier children: flexible nails vs rigid locked nails. J Pediatr Orthop 31(1):11-16
  46. Kanellopoulos AD, Yiannakopoulos CK, Soucacos PN (2006) Closed, locked intramedullary nailing of pediatric femoral shaft fractures through the tip of the greater trochanter. J Trauma 60(1):217-222 discussion 22-3
  47. Ziv I, Blackburn N, Rang M (1984) Femoral intramedullary nailing in the growing child. J Trauma 24(5):432-434
  48. Galpin RD, Willis RB, Sabano N (1994) Intramedullary nailing of pediatric femoral fractures. J Pediatr Orthop 14(2):184-189
  49. Gordon JE, Swenning TA, Burd TA, Szymanski DA, Schoenecker PL (2003) Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children. J Bone Joint Surg Am 85A(7):1295-1301
  50. Townsend DR, Hoffinger S (2000) Intramedullary nailing of femoral shaft fractures in children via the trochanter tip. Clin Orthop Relat Res 376:113-118
  51. Gonzalez-Herranz P, Burgos-Flores J, Rapariz JM, Lopez-Mondejar JA, Ocete JG, Amaya S (1995) Intramedullary nailing of the femur in children. Effects on its proximal end. J Bone Joint Surg Br 77(2):262-266
  52. Raney EM, Ogden JA, Grogan DP (1993) Premature greater trochanteric epiphysiodesis secondary to intramedullary femoral rodding. J Pediatr Orthop 13(4):516-520
  53. MacNeil JA, Francis A, El-Hawary R (2011) A systematic review of rigid, locked, intramedullary nail insertion sites and avascular necrosis of the femoral head in the skeletally immature. J Pediatr Orthop 31(4):377-380
  54. Miller DJ, Kelly DM, Spence DD, Beaty JH, Warner WC Jr, Sawyer JR (2012) Locked intramedullary nailing in the treatment of femoral shaft fractures in children younger than 12 years of age: indications and preliminary report of outcomes. J Pediatr Orthop 32(8):777-780
  55. Ramseier LE, Janicki JA, Weir S, Narayanan UG (2010) Femoral fractures in adolescents: a comparison of four methods of fixation. J Bone Joint Surg Am 92(5):1122-1129
  56. Cramer KE, Limbird TJ, Green NE (1992) Open fractures of the diaphysis of the lower extremity in children. Treatment, results, and complications. J Bone Joint Surg Am 74(2):218-232
  57. BOA/BAPRAS (2009) The management of severe open lower limb fractures. British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons Standard for Trauma (BOAST)
  58. Cashman JP, Bell MJ (2002) The multiply injured child. Curr Orthop 16(6):442-450
  59. Mendelson SA, Dominick TS, Tyler-Kabara E, Moreland MS, Adelson PD (2001) Early versus late femoral fracture stabilization in multiply injured pediatric patients with closed head injury. J Pediatr Orthop 21(5):594-599
  60. Hedequist D, Starr AJ, Wilson P, Walker J (1999) Early versus delayed stabilization of pediatric femur fractures: analysis of 387 patients. J Orthop Trauma 13(7):490-493
  61. Kocher MS, Sink EL, Blasier RD, Luhmann SJ, Mehlman CT, Scher DM et al (2010) American Academy of Orthopaedic Surgeons clinical practice guideline on treatment of pediatric diaphyseal femur fracture. J Bone Joint Surg Am 92(8):1790-1792
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