The management of paediatric diaphyseal femoral fractures: a modern approach

Abstract

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.

Keywords: Evidence; Femur; Fracture; Management; Paediatric; Review; Trauma.

Fig. 1

Paediatric diaphyseal classification system

Fig. 2

AP radiograph demonstrating a distal 1/3 spiral femoral diaphyseal fracture in a 6-year-old child

Fig. 3

AP radiograph of the same child as shown in Fig. 2, taken at 8 weeks, showing solid union and acceptable alignment after an initial treatment of 3- to 4-week in-line traction

Fig. 4

AP radiographs demonstrating a proximal 1/3 spiral femoral diaphyseal fracture in a 6-year-old child

Fig. 5

Lateral radiographs demonstrating a proximal 1/3 spiral femoral diaphyseal fracture in a 6-year-old child

Fig. 6

After 4 weeks in traction, a healthy callus is seen to form in children aged 5–12 years

Fig. 7

After 4 weeks in traction, a healthy callus is seen to form in children aged 5–12 years

Fig. 8

AP radiograph demonstrating a proximal third diaphyseal fracture of the femur in an 8-year-old. Note the spiral fracture with a butterfly fragment—elastic nails may be unstable here

Fig. 9

AP radiograph showing the patient from Fig. 8, treated with a submuscular 3.5-mm bridge plate. At just 8 weeks, there is abundant callus and the patient is fully weight bearing

Fig. 10

AP radiograph demonstrating a spiral femoral fracture ideal for treatment with flexible nails

Fig. 11

AP radiograph showing satisfactory restoration of length, rotation and alignment with the use of titanium elastic nails, of the fracture in Fig. 10

Fig. 12

Treatment of a femoral diaphyseal fracture in a 16-year-old girl. Note is made of the subtle nuances such as the narrow canal and non-fused physis which must be considered in the management of these fractures

Fig. 13

Treatment of a femoral diaphyseal fracture in a 16-year-old girl. Note is made of the subtle nuances such as the narrow canal and non-fused physis which must be considered in the management of these fractures

Fig. 14

Algorithm summarising the management pathways for paediatric femoral diaphyseal fractures