History
In most cases of proximal femoral fractures, there is a history of high-energy trauma, such as that caused by a fall from a height or a motor vehicle accident. These injuries are often associated with serious injuries to other organ systems and unconsciousness; convulsions; bleeding from the ear, nose, or throat; or breathlessness. A conscious patient complains of pain in the groin or buttock and an inability to walk after the injury.
Patients with a femoral shaft fracture usually have a history of a fall or a motor vehicle accident, with pain in the thigh and an inability to walk. The history, however, may be inadequate in patients with mental retardation, nonambulatory patients, patients with polytrauma, and patients with head injury. In pathologic fractures, there may be a history of pain in the thigh and a recent increase in the pain.
In the presence of traumatic brain injury, child abuse may be suggested in children younger than 4 years who have a history of injury discordant with fracture and multiple fractures in different stages of healing (see the image below). [12]
Spiral fracture of femoral shaft, with hypertrophic callus due to previous multiple fractures (a) in 2-year-old abused child treated with spica cast (b), showing union (c).
Physical Examination
The examination must be extensive, with care taken to rule out associated injuries to the head, chest, abdomen, and other skeletal sites. In proximal femoral injuries, the injured limb is short and lies slightly adducted and externally rotated. Tenderness can be elicited over the Scarpa triangle and, more commonly, posteriorly over the femoral neck region. Detailed examination of the peripheral pulses and the motor and sensory systems must be performed to rule out neurovascular injuries.
Femoral shaft fractures are hard to miss on examination; deformity, swelling, shortening, tenderness, abnormal mobility, and crepitus suggest the diagnosis. Nevertheless, a complete physical examination must still be performed to rule out associated injuries, especially in the setting of hypotension, which is rarely due to isolated femoral shaft fractures.
Rang described the Waddel triad of femoral shaft fracture, head injury, and intra-abdominal or thoracic injury caused by automobile-pedestrian collisions. [13] Common musculoskeletal injuries associated with femoral shaft fracture that are often missed include femoral neck fracture, hip dislocation, and ligamentous injuries of the knee.
Distal femoral fractures usually involve a relatively violent injury with resulting severe pain and inability to bear weight on the injured leg. Malalignment, swelling, and ecchymosis are frequently present. Salter-Harris type III and type IV fractures present as hemarthrosis of the knee.
The displacement of the epiphysis occurs most often in the coronal plane, and the protruding metaphyseal end can be palpated. With anterior displacement, the patella becomes prominent, and the metaphyseal end is felt as fullness in the popliteal fossa. A posterior displacement causes fullness in the lower thigh, caused by the protruding metaphyseal end. The patella and condyles are always in line with the tibia, ruling out knee dislocation.
A thorough neurovascular examination is warranted in all cases of distal femoral fracture.
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Arterial supply to head of femur in child.
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Depiction of various Delbet types of proximal femoral injury.
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Patterns of avascular necrosis in hip fractures in children.
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(a) Delbet type I proximal femoral epiphyseal injury. (b) Reduction and fixation with smooth pins. (c) Avascular necrosis 1 year after surgery. (d) Bone scan showing decreased vascularity of femoral head on affected side. (e) Radiograph after pin removal showing avascular necrosis (L) of hip.
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Spiral fracture of femoral shaft, with hypertrophic callus due to previous multiple fractures (a) in 2-year-old abused child treated with spica cast (b), showing union (c).
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(a) Comminuted fracture shaft of femur in adolescent. (b) Insertion of submuscular bridge plate through small distal incision. (c) Screw insertion through tiny stab incisions under imaging guidance. (d) Postoperative check film. (e) Tiny scars 3 months after surgery.
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Depiction of various Salter-Harris types of distal femoral epiphyseal injury.
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Type II distal femoral epiphyseal injury fixed with 2 smooth crossed pins.
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Schematic diagram showing various methods of operative fixation of distal femoral epiphyseal injuries.
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X-ray of adolescent who sustained sporting injury and fractured his right femur. Image courtesy of Dr. Bhavuk Garg, Senior Resident of Orthopedics, All India Institute of Medical Sciences, Delhi.
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Immediate postoperative x-ray of titanium elastic nailing performed on male child. Image courtesy of Dr. Bhavuk Garg, Senior Resident of Orthopedics, All India Institute of Medical Sciences, Delhi.
Tables
Delbet Fracture Type |
Recommended Treatment |
Remarks |
I (transepiphyseal) |
Gentle closed reduction and fixation with 2 or 3 smooth pins, followed by spica cast in abduction and internal rotation for 6-12 wk Repeated attempts at reduction should be avoided Irreducible fractures and fracture dislocations may require open reduction |
These fractures have highest rate of complications and worst prognosis Loss of reduction with varus deformity is frequent Premature physis closure and limb length discrepancy may occur AVN of femoral head is reported in 20-100% of cases |
II (transcervical) |
Gentle closed reduction and fixation with 2 or 3 threaded pins (young children) and 2 or 3 parallel screws (older children), followed by spica cast for 6 wk Implants must stop short of physis Hip decompression by needle aspiration may be added |
Loss of reduction and varus malunion are common if fracture is stabilized by external immobilization alone Decompression is reported to reduce risk of AVN in these cases; AVN is reported in as many as 50% of cases Nonunion is reported in 15% of cases |
III (cervicotrochanteric) |
Closed reduction and internal fixation with Kirschner wires or cannulated screws in all displaced fractures and undisplaced fractures in children >6 y Undisplaced fractures in children < 6 y can be treated with closed reduction and spica cast |
Conservative treatment in older children is associated with high rates of varus nonunion in some series Overall, these fractures have better outcome than type II fractures Reported incidence of AVN is 15-20% |
IV (pertrochanteric or intertrochanteric) |
Closed reduction and internal fixation with Kirschner wires or cannulated screws in all displaced fractures and undisplaced fractures in children >6 y Undisplaced fractures in children < 6 y can be treated with closed reduction and spica cast |
Conservative treatment in older children is associated with high rates of varus nonunion in some series These fractures have best prognosis These are extracapsular fractures and therefore less likely to cause direct vascular insult; reported incidence of AVN is 5% |
AVN = avascular necrosis. |
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Age |
Fracture Treatment |
Treatment |
Remarks |
Infants |
Stable/undisplaced |
Splint |
Suspect abuse or osteogenesis imperfecta Remarkable remodeling potential |
Unstable/angulated |
Pavlik harness, gallows traction, spica cast |
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1-6 y |
Stable fracture |
Immediate spica cast |
Telescope test to determine stability Skeletal traction in older, heavier patients |
Unstable fracture/unacceptable reduction |
Traction followed by spica cast |
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Multiple trauma |
Flexible intramedullary nails/external fixator |
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6-11 y |
Low-energy stable fractures |
Early spica |
Remodeling potential lesser than for younger children Operative stabilization indicated if early mobilization required Flexible intramedullary nailing preferred |
High-energy unstable fracture |
Traction followed by spica/plating/external fixator/flexible nailing |
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≥ 11 y |
|
Internal or external fixation; external fixator for comminuted, unstable, and compound fractures |
Operative stabilization preferred Limited remodeling potential Accurate restoration of length and alignment mandatory Rigid nailing through piriformis fossa should be avoided to reduce risk of avascular necrosis |
