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
Pediatric Femoral Shaft Fracture ICD-9
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.
- Delayed union
- 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