January 28, 2012

Treatment Option for Paediatric Femoral Shaft Fracture

Complete Spiral fracture with Displacement and shortening of Left femur in 6 years old child.

While plating or Intramedullary nail being a famous and traditional treatment for femoral shaft fracture in adult, it remain controversial for the pediatric population.

For ages, conservative treatment with Pavlik harness and early or delayed cast have being implied. Study has shown that it is effective even in a severely displaced fracture or shortening up to 2.5 cm. However, it cause prolong immobilization  leading to loss of school days and need of good nursing care.

Some literature may put a range of age of which treatment is the best but it remain subjective and depends on orthopaedist choice and agreement with the parent. Generally, conservative treatment is best reserved in children less than 5 years old and modality depends for children age from 6 to 13 years old. For the past few decades, the surgical management evolving very fast starting from the use of external fixator till the use of elastic platinum intramedullary nail.

After 2 weeks of skin traction, the shortening become lesser but still no callus formation seen

Various of method has being described and each of the treatment modalities has their own complication that should be discussed with parents.

Exernal fixator may cause pin tract inflammation and sepsis, malunion and refracture. But it may provide excellent result if the child being operated early within 24 hours of events even without prior traction. Usage of traction table prevent the malrotation and support the under leg and reduce the fracture before insertion of first pin.

Intramedullary nail fixation may give rise to avascular necrosis of the head of femur, coxa valga and physis disturbance

Plate and screws is a good choice to prevent rotational deformity and stabilize the fracture but it will leave a long scar, increased infection rate and require revision surgery later.

The problem with conservative treatment is the long duration of hospital stay and this will not only reduce the schooling time but also affect the working parent who needs to stay with child at wards for a long time. Besides, it may also affect the other siblings.

As a conclusion, the noble approach for modern management of paediatric fracture should shortened the hospital stay, comfortable, stabilize the fracture and less complication. This has led to many surgical approach to provide a better treatment for femoral shaft fracture in children. However, one should always bear in minds that the chosen method should spare the physis, not altering the vascularization of femoral head, as minimal invasive as possible and do not interfere with consolidation process or the fracture focus and stable enough as to not require additional casting for immobilization.[P. Gonzales-Herranz et al]

1) Frech-Dörfler M, Hasler CC, Häcker F-M, "Immediate hip spica for unstable femoral shaft fractures in preschool children: still an efficient and effective option",  Eur J Pediatr Surg 2010

2) Mukesh Kalra, Asif Mahmood & Mohit K.P, "Treatment of Pediatric Femoral Shaft Fracture with Titanium Elastic Nails- Our Experience", JCOT Vol 2, No 1, 2011

3) Peter Byass & Tedros A Ghebreyesus, "Pediatric Femoral Fracture", The Lancet, Vol 365, March 2005

4) Hanne Hedina, Sune Larsson, “Technique and considerations when using external fixation as a standard treatment of femoral fractures in children. ", Injury, Int. J. Care Injured (2004) 35, 1255—1263

5) P. Berger, J.S. De Graaf, R. Leemans, " The use of elastic intramedullaey nailing in the stabilisation of paediatric fractures", Injury, Int. J. Care Injured (2005) 36, 1217-1220, Elsevier

6) P. Gonzales-Herranz, M.L.I Rodriguez  Rodriguez & M.A. Castro Torre, "Diaphyseal Femur Fractures in Children. Treatment Update", Rev esp cir ortop traumatol. 2011; 55(1): 54-66

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