Pediatric diaphyseal femur fractures account for 1.7%1 of all pediatric fractures with the annual incidence estimated at 19 per 100,000.2,3 Treatment of pediatric femur fractures remains a variable and somewhat controversial topic among pediatric orthopedic surgeons. Of the AAOS Clinical Practice Guidelines for the treatments of pediatric femur fractures, only 2 have level I or level II evidence available at this time. Fracture management is influenced by associated injuries, patient age, fracture characteristics, body weight, and surgeon preference.
Pediatric orthopedic surgeons have tended to surgically manage femur fractures of older children and to conservatively treat femur fractures of younger children.4 Patients under the age of 5 can largely be treated with closed reduction and spica casting, whereas adolescents with a closed proximal femoral physis are most appropriately treated with rigid intramedullary nailing.5 Children between 6 years old and skeletal maturity continue to remain a difficult patient population that can be further complicated in the case of a length-unstable fracture. Length-unstable fractures are defined as comminuted or spiral fractures with >2 cm of shortening.3 The treatment of these fractures remains a debated topic. Historically, the management included the use of skeletal traction with delayed spica casting.6–8 Drawbacks of this technique include a lengthy hospital stay and the constant need of a caregiver.6,7,9 This practice has largely dissipated in favor of surgical stabilization. Prompt surgical treatment of length-unstable fractures allows patients early mobilization and decreased length of hospital stay. Options for surgical stabilization include open plating, external fixation, intramedullary fixation, and submuscular plate fixation. Each method has unique advantages and disadvantages, with the ideal treatment largely controversial.
Traditional open plating technique requires a sizeable exposure with significant soft tissue disruption and has been associated with femoral overgrowth secondary to periosteal stripping.10 External fixation has been well described in the literature with multiple complications including pin-tract infections and higher rates of delayed union, nonunion, malunion, and refracture.11,12 Flexible intramedullary nailing has become a popular method of treatment with good clinical outcomes and low complication rates in simple transverse factures.13–15 Recent studies have demonstrated an increased risk of complications when flexible nails are utilized in length-unstable fractures and heavier children.16–19 Previously, the use of rigid intramedullary nailing introduced through the piriformis fossa was utilized, but this technique has been associated with avascular necrosis of femoral head.20–22 Therefore, this technique has remained a relative contraindication in patients between the ages of 6 years old and skeletal maturity.
Submuscular plating is an established operative treatment for femur fractures,5,23,24 acting as an internal splint, providing stable fixation, and allowing for maximum biological healing. This minimally invasive operative technique protects the periosteal and endosteal blood supply as well as the soft tissue envelope. It preserves alignment and length in unstable fracture patterns that may be challenging to preserve with other techniques such a flexible nailing and spica casting.
The principles and technique of bridge plating of length-unstable fractures are now well described in the pediatric orthopedicliterature.5,23–25 Using this technique, the plate is fixed only to the 2 main fragments leaving the fracture zone relatively untouched to maximize the blood supply.
PRINCIPLES OF MANAGEMENT
Patients are positioned supine on a radiolucent fracture table. Utilizing in-line traction, the fracture is provisionally reduced. Fracture reduction is confirmed by anteroposterior and lateral fluoroscopic views. The goal of provisional reduction is to restore length, angular, and rotational alignment. Anterior bowed, femoral locking plates (Synthes, West Chester, PA; OrthoPediatrics, Warsaw, IN; and Smith & Nephew, Andover, MA) of 3.5 or 4.5 mm size are selected and precontoured by placing the plate on top of the thigh under radiographic imaging. Utilizing a plate bender, the proximal and distal ends of the plate are properly bent to match the flare of the metaphyseal regions of the femur (Fig. 1). The contour of the properly bent plate can be used to affect the coronal alignment of the fracture. The plate should span the length of the femur from just below the greater trochanteric apophysis to the metaphysis of the distal femur.25 Typically, 10 to 18 hole plates are used depending on 2 factors, location of the fracture and femur length.
Proximal and distal incisions are made to allow for the advancement and fixation of the plate. The distal incision is made first as it typically begins at the level of the physis and extends proximally. Dissection is carried down to the iliotibial band, which is split in-line with the skin incision. The vastus lateralis is elevated anteriorly allowing for extraperiosteal dissection to be accomplished. Proximally, the incision originates at the trochanteric apophysis and extends distally approximately 2 to 3 cm. Utilizing a muscle-splitting technique, extraperiosteal dissection may be completed (Fig. 2).
The precontoured plate is passed in a retrograde manner along the shaft of femur until it is seen in the proximal incision. K-wires are placed at the proximal and distal ends of the plate to allow for a provisional reduction. Under radiographic imaging, the plate’s position is confirmed with anteroposterior and lateral views (Fig. 3). To reduce the plate to the femur, standard cortical screws are placed in the proximal and distal ends of the plate. If further reduction is necessary, stab incisions can be completed on the lateral aspect of the thigh. Percutaneous fixation can be accomplished with either a screw or a temporary threaded device. Locking screws are placed to enhance the stability of the construct (Fig. 4). Final images are obtained to confirm the position of the plate and screw.
Our postoperative care involves toe-touch weight-bearing for 2 to 4 weeks, followed by a return to activity as tolerated. Patients are seen at 2, 6, and 12 weeks from the date of surgery. Plate removal is recommended in the younger patient because of the possibility of bony overgrowth and distal femoral valgus. As the distal femoral physis grows away from the plate and the distal femoral metaphysis remodels, the distal screws may become prominent medially. Plate removal is typically performed between 6 months and 1 year after the initial surgery. Plate removal is performed under direct visualization through the same proximal and distal incisions. This technique reduces radiation exposure and decreases fluoroscopy times. If the plate is removed at a later time, the potential of tissue overgrowth may make removal through the same percutaneous incisions more difficult.
Complications after submuscular plating are rare. Proper plate bending can help avert fracture malunion. Heyworth et al26 demonstrated a distal femoral valgus deformity occurred in 30% of patients with distal diaphyseal fractures and in 12% overall after plate fixation. Malrotation is possible as intraoperative assessment can be difficult using the submuscular technique. Kanlic et al27 reported 2 potential complications, 3.5-mm plate bending after fixation and refracture after early plate removal. Both complications may have been prevented with the use of a 4.5-mm plate in most patients other than those with small femurs and refraining from plate removal until complete healing is present. In addition, there is a potential for loss of femoral anterior bow in fractures after radiographic union, but this has not been found to be of clinical relevancy. Lastly, there is the potential for femoral overgrowth.
Over the past decade, surgical stabilization has gained favor in the management of femoral shaft fractures in the pediatric population. The use of indirect reduction techniques has evolved, and the practice of utilizing longer plates has provided a more stable construct for the pediatric femur fracture.
Rozbruch et al28 assessed the evolution of techniques used in femoral shaft plating. They evaluated 3 decades of results of femur fracture plating techniques looking at the use of indirect reduction, longer plates, and fewer screws. That includes lag screws and screws in the plate. The best predictor of a positive outcome was the length of the plate. In length-unstable fractures treated with this technique, the longer plate increases the working length of the construct and decreases the strain on the plate.23,24,29,30 Apivatthakakul et al30 found this construct reduced the risk of plate failure when used to treat comminuted fractures. As the comminuted fracture is bridged with a long plate, the stress on the healing fracture is significantly less.
In 2003, Ağuş et al31 evaluated bridge plating of comminuted femoral shaft fractures. Fourteen pediatric patients with an average age of 11.3 years were treated over a 5-year period. Their technique utilized a proximal and distal incision to the fracture with no opening of the fracture site. All patients went onto union at an average of 12.4 weeks with no reported complications of rotational deformities or leg-length discrepancies. Kanlic et al27 in 2004 in a multicenter study evaluated the use of submuscular bridge plating for complex fracture patterns in 51 patients. They concluded that this technique offers the advantage of adequate stability for early functional treatment and predictable healing with maintenance of length and alignment for all pediatric femoral shaft fractures.
Sink et al23 in 2006 described their technique and results for bridge plating of femur fractures. The study included 27 patients at 2 different pediatric trauma centers over a span of 2 years. Their technique involved 1 distal incision with multiple small incisions for percutaneous screw placement. No intraoperative or postoperative complications occurred and all fractures went onto union by 12 weeks. Elective plate removal took place at 6 to 8 months through the same incisions with no complications. No refractures occurred after plate removal.
In 2013, Samora et al24 identified 32 patients with length-unstable femur fractures treated with submuscular bridge plating at a level-1 pediatric trauma center. The mean time for full weight-bearing was 8.1 weeks with all fractures healing in 12 weeks. No intraoperative complications occurred. There were no cases of malalignment >10 degrees at follow-up. Class I heterotopic ossification occurred in 3 patients (Fig. 5).
We have had success at our institution when using submuscular plating to treat complex femur fractures. We recently conducted a retrospective review of 196 skeletally immature patients aged 8 and older who were treated for a femur fracture with submuscular plating, flexible intramedullary nailing, or rigid intramedullary nail from 2001 to 2014 with a minimum 12-week follow-up. Treatment outcomes were evaluated among the 3 groups. Thirty-five patients were treated with submuscular plating, experiencing faster times to full weight-bearing, excellent healing, and minimal complication rates.
There are multiple surgical options in the treatment of pediatric femoral shaft fractures. Submuscular bridge plating is a suitable treatment alternative in the management of skeletally immature patients with length-unstable pediatric femur fractures. This technique provides excellent healing rates, rapid return to full weight-bearing, low complication rates, and allows for simplified hardware removal. Further prospective outcome and comparison studies are needed.
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Keywords:Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
femoral shaft fracture; submuscular bridge plating; evidence-based medicine