What’s the best way to stabilize a bad fracture of the femur (thigh bone) in children while minimizing pain, maximizing comfort, and preventing scarring or complications? That’s the topic of this article on current strategies for the management of children’s femur fractures.
The truth is there is no known “ideal” method. There is no evidence to suggest one surgical treatment technique outshines all the rest. Currently, the types of surgical stabilization available include elastic stable intramedullary nailing, locked intramedullary nails, plate fixation, and external fixation. Each one of these approaches, along with the advantages and disadvantages are discussed in detail.
But before we fill you in on the surgical side of femoral fracture fixation, let’s take a quick look at nonoperative management. Cast immobilization is a possibility for some children. The cast goes from hip to toes and is called a spica or hip spica cast. Conservative care of this type is possible when the patient is a young child or a small child (up to 60 pounds).
The benefits of this type of treatment include no surgery, very short time in the hospital, avoiding scars from surgical incisions, and preventing infection. The downside of cast immobilization includes the child has to wear a hot, bulky cast and the parents have to care for the child who can’t bend at the waist, roll over, use a toilet, or walk.
There is also the possibility that the fracture will heal improperly when only held in place by a cast. The fracture might separate, a process called “loss of reduction.” Or the broken bones could shift the other way, overlapping each other causing shortening of the leg. But, if it doesn’t work, the child could always still have surgery.
Let’s consider the pros and cons of surgical fixation. Elastic, slightly flexible long nails have been in use for the last 20 years. Titanium has replaced stainless steel making it possible to have a narrow, lighter, less rigid rod down the center of the bone. The child does not have to be in a cast or brace and that is a big advantage. The flexibility of the nail(s) makes it possible for the fracture to withstand some load or force without losing stabilization.
There is some debate about whether or not the nails should be removed after the fracture has healed fully. Pulling the nails back out means another set of small incisions. Sometimes the nail doesn’t come out easily or breaks in the process. That can add another dimension of complexity. While the nails are in place, there can be some irritation and pain at the site where the nail was inserted.
The more rigid locked intramedullary nails are used for adults but also work well for older children/teens or heavier children. They are also the best choice when the fracture site is broken into many little pieces of bone or unstable for any other reason. This type of fixation does not have to be removed.
Another option to choose from is plate fixation. This is a long metal plate that attaches along the bone inside the body with screws through the plate crosswise into the bone. This does require open surgery with incisions that leave scars. Surgeons are also finding ways to slip the plate in through the skin under the muscle. This is more of an indirect technique. Once again, the plates used in this type of fixation would be left in place rather than removed after fracture healing.
The last type of fixation is referred to as external fixation. It is a metal cage that fits around the outside of the leg with multiple long pins crosswise through the bone. External fixation is not used much anymore now that flexible nailing is possible. There were just so many complications with this type of fixation. Infections, loss of reduction, delayed union, ugly scars, and refracture are just a few of the problems reported with this type of fixation. External fixation is still used in cases of extreme trauma or severe, open fractures but for the most part it has been replaced with the flexible nails.
In summary, there isn’t enough evidence to support one single fixation technique over others for femoral fractures in children. The surgeon will weigh all of the pros and cons of each approach and evaluate each child individually when deciding what is best. Factors that must be taken into consideration include the child’s age, weight and size, and type and severity of fracture. The surgeon’s own level of experience and expertise will make a difference along with any other injuries (especially soft tissue trauma) affecting the leg.