Femur Fracture – Fracture of the Thigh Bone
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:
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.
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.
These are a series of pictures of a child with a femur fracture that has been treated in a spica cast. The cast has been applied, but the ends of the bones are still overlapping and don’t line up perfectly!!!
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…
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.
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.
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. The advantages of ORIF is that the bone can be restored to its anatomicposition and alignment. However, the disadvantages are that this may result in significant fracture overgrowth and a limb length inequality. The plate must eventually be removed, and a very large scar is left behind.
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.
Here are a series of before and after pictures of a femur fracture treated with external fixation. Two pins above the fracture and two pins below the fracture have been connected by a frame in order to hold the broken pieces of the femur in good alignment.
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.
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.
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.