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Pediatric Femoral Shaft Fracture S72.309A 821.01

Pediatric Femoral Shaft Fracture

Pediatric Femoral Shaft Fracture

femur bone anatomy

thigh cross section anatomy

Pediatric Femoral Shaft Fracture

Pediatric Femoral Shaft Fracture

Pediatric Femoral Shaft Fracture

Pediatric Femoral Shaft Fracture

Pediatric Femoral Shaft Fracture

Pediatric Femoral Shaft Fracture

Pediatric Femoral Shaft Fracture

synonyms:

Pediatric Femoral Shaft Fracture ICD-10

 

A- initial encounter for closed fracture

B- initial encounter for open fracture type I or II

C- initial encounter for open fracture type IIIA, IIIB, or IIIC

D- subsequent encounter for closed fracture with routine healing

E- subsequent encounter for open fracture type I or II with routine healing

F- subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

G- subsequent encounter for closed fracture with delayed healing

H- subsequent encounter for open fracture type I or II with delayed healing

J- subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

K- subsequent encounter for closed fracture with nonunion

M- subsequent encounter for open fracture type I or II with nonunion

N- subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

P- subsequent encounter for closed fracture with malunion

Q- subsequent encounter for open fracture type I or II with malunion

R- subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

S- sequela

Pediatric Femoral Shaft Fracture ICD-9

  • 821.01(closed)
  • 821.11(open)

Pediatric Femoral Shaft Fracture Etiology / Epidemiology / Natural History

Pediatric Femoral Shaft Fracture Anatomy

Pediatric Femoral Shaft Fracture Clinical Evaluation

  • ATLSresuscitation. These can be high enegery injuries, assessment should begin with the A,B,C's.
  • Obvious deformity of thigh often with limb shortening
  • Document neurovascular exam before and after any treatment.
  • Evaluate for hemarthrosis: indicates associated meniscal tear or knee ligamentous injury.

Pediatric Femoral Shaft Fracture Xray / Diagnositc Tests

  •  A/P and lateral views of femur. High quality A/P and lateral views of the hip and knee are indicated to r/o associated injuries, especially femoral neck fractures.
  • CT: consider fine cut CT through the femoral neck if concern for associated femoral neck fracture (Tornetta P, JBJS 2007;89A:39).

Pediatric Femoral Shaft Fracture Classification / Treatment

  • Spiral, transverse, oblique, greenstick, comminuted. Proximal midshaft, distal, pathologic
  • Treatment options: pavlic harness, walking spica cast, standard spica cast,  Ex Fx, Flexible IM nail, Rigid IM nail, submuscular plating / ORIF, traction
  • Acceptable alignment at union for 2-10yr olds: <15 varus or valgus, <20 anterior or posterior, ,<30 malrotation, <2.0cm shortening.
  • Infants(1-6 months) = pavlic harness +/- supplemental splint. Fractures of the femur in newborns heal very rapidly.  Infants adapt rapidly to the harness, and can be carried and held by the parents, facilitating mother-child bonding (Stannard JP, JPO 1995;15:461-466) (Podesszwa DA, JPO 2004;24:460). Evaluate for child abuse.
  • 6months - 5years with less than 2cm of shortening =early spica casting; f.u xray at 7-10 days;  cast removed when early callus is present, usually 6-8 wks. (Epps HR JPO 2006;26:491). Children <36months old with femur fractures should be evaluated for child abuse.
  • 6months - 5years with greater than 2cm of shortening =AAOS guideline reports treatment recommendation is inconcluslive. Consider early spica casting vs flexible nails (older, heavier children). Children <36months old with femur fractures should be evaluated for child abuse.
  • 5-11yrs=flexible (titanium elastic) intramedullary nails. Consider external fixation, ORIF. Severely comminuted and length-unstable femur fracture consider submuscular bridge plating (Hedequist DJ, Sink E. Technical aspects of bridge plating for pediatric femur fractures. J Orthop Trauma. 2005 Apr;19(4):276-9).
  • 11-16yrs= transtrochateric nail; mayconsider external fixation, ORIF. Piriformis entry nails should not be used.
  • Pediatric Femoral Shaft Fracture Flexible Nail 27506-
  • Pediatric Femoral Shaft Fracture External Fixation 20690=unilateral lateral ex fix, generally four pins. Transverse fractures treated with an external fixator heal with poor callus and have a high refracture rate. May also refracture through pin sites. Consider frame dynamize before removal (GreenWB:CORR 1998; 5:86). (Gregory P, JOT 1996;10:191), Blasier RD, JPO 1997;17:342).
  • Traction=. Femoral pin traction is safe and effective but requires prolonged bed rest and results in considerable muscle wasting and a slow return to function.
  • Rigid IM nailing can be done through greater trochanter.  Piriformis fossa starting point risks AVN. )(Kanellopoulos AD, J Trauma 2006;60:217).
  • ORIF= effective, but requires considerable tissue dissection with large scar formation.  It also requires a rather extensive dissection for later plate removal )Caird MS, JPO 2003;23:448). (Hedequist DJ, JOT, 2005;19:276).
  • Traction-prolonged bed rest(3-4wks), muscle wasting, slow return to function

Pediatric Femoral Shaft Fracture Associated Injuries / Differential Diagnosis

  • ChildAbuse: especially before walking age. buckle fracture is consistent with child falling on their own leg; spral fracture = child landing while in motion; transverse fracture = older, heavier person falling onto child.

Pediatric Femoral Shaft Fracture Complications

  • Leg Length Discrepancy 736.81: overgrowth common in ages 2-10y/o.
  • Infection
  • Delayed union
  • Nonunion
  • Vascular injury
  • Compartment syndrome
  • tibial physeal closure and development of genu recurvatum deformity (Bowler, J Pediatric Orthop 10:653;1990)
  • Painful hardware (pain at flexible nail insertion site)

Pediatric Femoral Shaft Fracture Follow-up Care

  • Time to union is 8-10 weeks.
  • Consider Hardware removal after fracture union. Generally at 6-12 months. Need for hardware in asymptomatic patients in inconclusive.

Pediatric Femoral Shaft Fracture Review References

  • AAOS Pediatric Femur Fracture Guidelines.
  • Ligier JN, Metaizeau JP, Prevot J, Lascombes P: Elastic stable intramedullary nailing of femoral shaft fractures in children.  J Bone Joint Surg Br 1988;70:74-77.
  • Heinrich SD, Drvaric D, Darr K, MacEwen GD: Stabilization of pediatric diaphyseal femoral fractures with flexible intramedullary nails (a technique paper).  J Orthop Trauma 1992;6:452-459.
  • Flynn JM, JBJS 2004;86:770
  • Kocher MS,  Treatment of pediatric diaphyseal femur fractures. J Am Acad Orthop Surg. 2009 Nov;17(11):718-25
  • Canale ST, ICL 1995;44:255

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