Femoral Fractures

Femoral Fractures

Open femoral fractures are rare but severe injuries. Hutchins
et al. reported that thirty-two (4%) of 712 femoral fractures
treated at a large urban pediatric trauma center from 1985 to
1996 were open26. Of forty-three children with a total of fortyfour
open femoral fractures (twenty-five type I, nine type II,
and ten type III) treated at two centers, thirteen were treated
with a spica cast; twelve, with external fixation; fourteen, with
locked intramedullary nailing; three, with open reduction and
internal fixation; and two, with pins and a plaster cast. Complications
in the patients with a type-I fracture included two
cases of malalignment requiring manipulation following
treatment with a spica cast, one case of osteonecrosis of the
femoral head following rigid intramedullary nailing, and one
case of unacceptable shortening requiring conversion from a
spica cast to external fixation. One patient with a type-II fracture
required an osteotomy and intramedullary nailing fol.
An open tibial fracture sustained by a ten-year-old boy who also
sustained multiple other injuries. Following irrigation and debridement,
the fracture was treated with a flexible intramedullary
rod that was placed proximally to avoid the tibial physis and tibial
tubercle.lowing a malunion after initial treatment with a spica cast.
Osteomyelitis developed at the sites of five of the ten type-III
fractures, and two type-III fractures treated with an external
fixator went on to malunion requiring corrective osteotomy 26.
The authors concluded that type-I and II fractures can typically
be treated with irrigation and débridement followed by
age-appropriate fixation methods, whereas the optimal fixation
for type-III fractures remains unresolved. Another series,
of eleven open femoral fractures, demonstrated faster healing
of lower-grade injuries and in younger children 66.
Open femoral shaft fractures in children younger than
the age of six years may be treated with irrigation and débridement
and a spica cast, although soft-tissue management is often
a problem when a spica cast is used. Fixation with a
traditional compression plate is an option for comminuted
open diaphyseal fractures of the femur in children 67, although
it is rarely the treatment of choice. Early results in small series
in which a submuscular bridge plate was used for open and
comminuted femoral fractures in children 68,69 appear encouraging,
as these procedures require less initial soft-tissue dissection
than does traditional plate fixation. External fixation was
widely used for open femoral fractures in children in the past.
However, because of a high refracture rate, substantial scarring,
and delayed unions, the present trend is for external fixation
to be employed primarily for fractures that are not
amenable to flexible nailing because of their location, their
configuration, or soft-tissue considerations.
Few other authors have exclusively examined open femoral
fractures in children, but most major series of femoral fractures
in children have included both open and closed injuries.
Flexible intramedullary nailing has become a preferred treatment
for diaphyseal femoral fractures in children 70, especially
those between the ages of six and twelve years. Numerous studies
have demonstrated excellent results, with no nonunions or
malunions, in children treated with flexible intramedullary
femoral nailing 71-74. Those studies have shown dramatically earlier
walking, shorter hospital stays, decreased healing times, and
earlier return to school compared with those results following
treatment with either external fixation 72 or a spica cast 74 in agematched
patient groups......