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.
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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