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Femur fractures are common
in children. They are the unfortunate
result of high velocity trauma such as auto-pedestrian accidents or auto-bicycle
accidents. The femur is the strongest
long bone in the body and it takes considerable force to break it.
Despite this, the femur has an incredible capacity to heal. There is
considerable controversy regarding the best way to treat femoral shaft
fractures in children. Much of
the treatment decisions are made based on the severity of the fracture,
the age of the child, and the treatment preferences of the surgeon. There is a recent, increasing trend to treat
femur fractures in children with surgery.
These options should be discussed with your treating surgeon so
that you understand their rationale for recommending a specific treatment.
Some of the treatment options are as follows: |
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Traction
followed by casting: This is the
traditional form of treatment
of femur fractures in children. Typically,
a traction pin is inserted into the femur to tibia and attached to weights
hung off the end of the bed. In
doing this, the length and alignment of the broken femur is maintained
until the healing process begins. Once
the fracture is making “callus”, then the child will be placed in a SPICA
cast. The use of
traction and spica casting has a long-term track record with good results. Disadvantages of this technique include the
need for a long, expensive hospitalization and a significant amount of
time missed from work for the parents. |
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Immediate
SPICA casting Immediate
SPICA casting is an optimal way to manage the majority of femur fractures
in children under about 10 years of age.
Despite the immobility and inconvenience that is imposed on the
child and the family by being in the cast, it is very effective in maintaining
appropriate length and alignment of the fracture. Healing is certain, and the re-fracture rate is low. SPICA casting is the most commonly used method
to treat most femur fractures in younger children. |
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| Don't worry, this fracture will heal just fine. Growing children will remodel broken bones over time, so that the fracture becomes less and less noticeable. Here, four weeks later, the ends of the bone are starting to grow together... | ||||
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| And here, the bones are growing together even more smoothly. The process of remodeling is quite remarkable, but it is not always possible to control precisely. When a bone has been broken in a growing child, that bone becomes very active and is stimulated to heal. This can actually cause the bone to grow longer than the one on the other side and is the reason why a difference in leg lengths is often noticeable after a femur fracture has healed. | ||||
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Flexible
Intramedullary Nailing Flexible
intramedullary nailing is gaining popularity as a way to treat pediatric
femur fractures. Flexible nails
are surgically inserted through the end of the femur just above the growth
plate and passed across the site of the femur fracture.
In doing this, the fracture alignment is maintained during the
healing process. Once the fracture
is completely healed (at least 4 months) the flexible nails are then removed. This technique is relatively new and the long-term results are not known. It offers the advantage of not needing a SPICA cast during the healing process. |
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Open
reduction and Internal Fixation Open reduction
and internal fixation , referred to as an “ORIF”, is an alternative to
putting the ends of the broken femur back together.
This is typically done using a rigid plate and screws. It requires a large incision along the thigh
to gain access to the broken bone. |
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External
Fixation The use of
external fixation refers to stabilizing the femur fracture by drilling
large pins through the skin into the bone and attaching them to an external
device that maintains the length and alignment of the broken femur. The advantages of external fixation are that
it allows the child to be mobile on crutches or in a wheelchair without
the need to use a SPICA cast. The
disadvantages are that there is a significant incidence of re-fracture
after the device is removed, and in some instances, the over time of treatment
is prolonged. |
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| Once the femur has healed, the external fixator is removed. In the picture on the left, you can see that the holes where the pins went through the bone are still visible. While these holes will fill in over time, they can be a source of weakness in the bone (called a stress riser) after the frame has been removed. As many as 25% of children who have a fracture treated with an external fixator will have another fracture right after the pins have been removed if they are not careful and start running around and jumping up and down too soon. | ||||
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Rigid
Intramedullary Nailing Rigid intramedullary
nailing is gaining popularity, especially in children older than 10 years
of age. Rigid intramedullary nails provide immediate stable fixation to
the broken femur, and allow the child to be up and around on crutches
in a matter of days. Healing is
certain, and the alignment is near normal.
A significant concern about the technique of rigid intramedullary
nailing is that if the insertion site of the nail is placed in the same
way that it is in an adult, it can put the blood supply of the ball of
the femur (hip joint) at risk. Therefore,
pediatric orthopedic surgeons prefer what is known as a trochanteric entry
point for placement of the nail, which avoids this potential problem.
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| Here are two before and after pictures of a femur fracture treated with an IM nail. You can see that the fragments of bone in the picture on the left have healed and become smooth again in the picture on the right. | ||||
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