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Femoral Shaft Frx in Infants: 0 to 2 yrs

- Discussion: - child abuse: child abuse occurs in 50-80% of children < 2 yrs w/ femoral frx; - limb length inequality are seldom a problem since frx does not shorten excessively; - acceptable reduction: - in children younger than 2 yrs, shortening of up to 1-1.5 cm & angulation of 30 deg are acceptable;

- Radiographs:

- Treatment: - early spica cast is often possible, if there is an acceptable reduction; - w/ an unacceptable reduction, consider a period of skin traction using modified Bryant's traction (thighs in 45 deg flexion and 30 deg abduction); - both legs need to be placed in traction to stabilize the pelvis; - contraindicated after the age of 2 yrs or w/ weight more than 25 lbs; - deligent skin care is a requirement; - union occurs in about 2 weeks; - leg weakness and/or limp may persist for one year; - in the report by S Morris et al (JPO 2002), the authors undertook a study to assess their incidence and outcome; - 7 patients from a total of 55,296 live births suffered 8 femoral fractures (incidence 0.13 per 1,000 live births); - twin pregnancies, breech presentations, prematurity, and disuse osteoporosis were associated with the occurrence of a fracture; - variety of treatment modalities were used, including gallows traction, spica cast, and Pavlik harness; - all patients in this study, regardless of treatment, had a satisfactory clinical outcome, with no evidence of limb length discrepancy or angular deformity on follow-up; - ref: Changing Patterns of Pediatric Pelvic Fractures With Birth-Associated Femoral Fractures: Incidence and Outcome S Morris. J Pediatr Orthop 2002 January/February;22(1):27-30

Discussion: - child abuse: 30% of femoral frx in children < 4 yrs are 2nd to child abuse;

- Over-riding of Fracture Fragments:

- in children between the ages of 2-10 yrs, overgrowth averages 0.9 cm; - in kids between 2 & 10 yrs, side to side apposition w/ 0.5 to 1 cm overriding is the ideal position; - in children below ages of 8- 9 yrs, up to 2 cm of bayonet apposition can be accepted with no long-term adverse effects; - overgrowth usually corrects most of the discrepancy; - some workers still incorporate a femoral pin in the cast; - references: - Femoral shaft fractures in children: the effect of initial shortening on subsequent limb overgrowth. - Fractures of the femoral shaft in children. The overgrowth phenomenon.

- Angulation at Frx Site: - saggital plane tolerates 20-30 deg angulation (accept less in older child); - frontal plane tolerates 10-15 deg angulation; - late angulation is managed w/ wedging of the cast;

- Treatment: - acceptable reduction: - in this age group, can be treated w/ early spica cast unless the frx overrides > 2 cm; - spica cast is left on for approximately 6-8 weeks; - unacceptable reduction: (more than 2 cm overriding); - w/ significant shortening of limb at frx site, consider a period of 90-90 deg skin traction (in younger children) or distal femoral pin traction (in older children) to maintain adequate limb length until early callus forms, then apply spica 1-2 weeks later; - during the period of traction, the hip usually needs to be flexed upto 90 deg and knee flexed 90 deg inorder to obtain reduction during early phase of frx healing; - after frx becomes sticky, less hip and knee flexion may be acceptable; - need to obtain weekly radiographs to follow frx alignment and length; - once frx site is less tender and once radiographs show early callus, traction may be discontinued;

- skin traction technique pearls: - apply moleskin strips or Skin-Trac strips directly to skin; - use no more than 7 lbs of traction force; - in some cases, a distal femoral traction pin may be incorporated into the spica cast (and is left in place for 3 weeks); - flexible IM nails:

Femoral Shaft Frx: Children aged > 10 yrs

- See:

- Femoral Traction Pins:

- Discussion: - from 10 to 15 yrs, consider 90/90 skeletal traction; - in this age group, skeletal traction is usually needed to achieve satisfactory alignment and minimize the overiding of the frx fragments until callus forms at about 3 weeks; - after 3 weeks apply Spica Cast: - potenial for shortening is greater in this age group, & further the potential for growth acceleration is much declined; - union requires 6 weeks; - after age 15 treat like an adult;

- Radiographs:

Overview

Despite the size and strength of the femur (the bone in the thigh), fractures in childhood are not uncommon. A motor vehicle accident, a fall from a piece of playground equipment, or even a piece of furniture at home may result in a broken leg that can range in severity from a simple hairline crack to a complex injury that also involves damage to surrounding soft tissues.Treatment

As in adults, treatment goals for children include achieving proper realignment of the bone, promoting rapid healing, and returning the patient to normal activities. However, there are also unique factors and considerations in the treatment of broken bones in children, says David M. Scher, MD, Associate Orthopedic Surgeon at Hospital for Special Surgery (HSS). “Along with such considerations as the configuration of the fracture; the ‘energy’ of the injury; and the amount of soft tissue injury present, pediatric orthopedists are also guided by age and size of the patient; the amount of growth remaining; and the potential for any shortening of the bone which sometimes occurs at fracture sites."

Newborns and Infants

Femur fractures in newborns are unusual, but can occur, for example, in babies born with a skeletal dysplasia such as osteogenesis imperfecta - also known as brittle bone disease - or sometimes following a very difficult delivery. Fractures in these very young children and in infants are usually treated by placing the child in a Pavlik harness, a cloth brace that helps hold the thigh in the proper position while it heals. “At this young age, children’s bones heal very rapidly, usually by 3-4 weeks,” says Dr. Scher.

Figure 1: Image of Pavlik harness on a child with developmental hip dysplasia.

Unlike the healing process in adults, a certain amount of variation in alignment of the bone as it heals is acceptable in infants and older children, notes Dr. Scher. As the body lays down new bone, over time, there is an automatic “correction” or straightening during growth, called remodeling.

Toddlers to Age 5

Among children in this age group, femur fractures usually result from a low energy fall. In most cases, the orthopedic surgeon realigns the fracture using fluoroscopy or x-ray imaging as a guide and immobilizes the leg in a type of cast called a spica cast. This procedure takes place in the operating room and a pediatric anesthesiologist is present to administer a sedative or general anesthesia to keep the child comfortable.

While casting techniques vary among orthopedic surgeons, for femur fractures the spica cast usually extends from mid-chest down the length of the affected leg and halfway down the other leg. “This allows us to best control the fracture and keep it from shifting out of place,” explains Dr. Scher.

Figure 2: A young patient in a spica cast, which immobilizes the leg after realignment.

Children remain in the spica cast for a period ranging from six weeks to three months. “Maintaining hygiene and keeping the child distracted and happy can be a challenge for the parent,” says Dr. Scher. “However,” he adds, “applied correctly in appropriately selected patients, spica casts remain the safest and least complicated way to treat these fractures and generally yield excellent results.”

Figures 3, 4: X-ray of a femur fracture with spica cast (top), and 10 months after injury and removal of spica cast (bottom). [Click on the images to view in a larger size.]

Following treatment, the orthopedic surgeon continues to monitor the patient for a period of several years to ensure that there is no limb length discrepancy. “When a fracture in the shaft of the femur occurs, the bone tends to shorten at the point where it breaks, Dr. Scher explains. “Later on, as healing occurs among children in this age group, the bone tends to grow longer; this is a phenomenon called “overgrowth” that may be caused by increased blood flow to the fracture site.” In some patients this initial shortening, combined with the subsequent increased growth, “cancel” one another out. However, in those cases where a small limb length discrepancy occurs, the orthopedic surgeon can use a relatively simple technique, such as growth modulation of the longer leg, to address this issue.

Age 5 to 10 years

Over the last decade many pediatric orthopedists have started using intramedullary nails or rods made from strong, lightweight, and flexible titanium to stabilize femur fractures

in children aged five and older. In a relatively simple technique, the orthopedic surgeon makes two small incisions - about one inch in length - on either side of the knee. After the bone is realigned, the nails are inserted up through the center of the bone where they act as an internal splint during healing.

Figure 5: X-ray showing flexible intramedullary nails in place. [Click on the image to view in a larger size.]

Intramedullary nails come in a range of diameters to accommodate the varying size of children’s bones. “Generally no casting is necessary,” Dr. Scher says, however a knee immobilizer is commonly used for a few weeks to prevent movement and to keep the child comfortable. In most cases, three to six weeks of early healing is necessary before the child can begin walking on the injured leg. When the bone is completely healed, usually around one year after the injury occurs, the child returns to the hospital to have the nails removed.

“Intramedullary nails are usually very well-tolerated,” says Dr. Scher. “They are particularly useful in five- to ten-year-old children who have a thick lining around the bone called the periosteum, which might be likened to the peel on a banana. The periosteum helps keep the bone more stable and reduces the need for a heavy and rigid device, such as those that might be used in adults.”

Older children and adolescents

Intramedullary nailing can also work well in older or heavier children, typically those over age 10 and heavier than 100 pounds; however, a single, thicker, more rigid nail is used rather than the smaller flexible nails. In these children, the nail is inserted through the top of the femur, near the hip, at a point called the greater trochanter, and locked into place with a screw at the top and the bottom of the bone. This placement avoids interruption of blood flow to the ball of the hip joint, which can lead to disabling arthritis. These concerns are not present in adults because they have different anatomy. In order to minimize the risk of complications when using intramedullary nailing in children, the orthopedist uses different devices and techniques than they would use in adult patients.

Figure 6: X-ray showing a rigid intramedullary nail in place. [Click on the image to view in a larger size.]

Submuscular plating is another treatment option for older and larger children. In this procedure, using x-ray images for guidance, the orthopedic surgeon inserts a stainless steel plate under the muscles of the leg and across the fracture site. Through small incisions in the skin, screws are placed through the plate and bone, above and below the fracture to hold it in place. Although this technique is minimally invasive, removal of the plate is more difficult than removal of intramedullary nails. “Currently, there is some discussion ongoing in the orthopedic community regarding the need to remove the plates at all,” Dr. Scher says.

In addition to the approaches described, the fallback treatment for a femur fracture in any age child is external fixation. This technique involves the use of rigid metal rods or circular rings and pins inserted into the bone to maintain alignment during healing.

Treatment

To treat a child's thighbone fracture, the pieces of bone are realigned and held in place for healing. Treatment depends on many factors, such as your child's age and weight, the type of fracture, how the injury happened, and whether the broken bone pierced the skin.Nonsurgical TreatmentA young child in a hip spica cast to immobilize a femoral shaft fracture.Courtesy of Texas Scottish Rite Hospital

In some thighbone fractures, the doctor may be able to manipulate the broken bones back into place without an operation (closed reduction). In a baby under 6 months old, a brace (called a Pavlik Harness) may be able to hold the broken bone still enough for successful healing.

Spica casting. In children between 7 months and 5 years old, a spica cast is often applied to keep the fractured pieces in correct position until the bone is healed.

There are different types of spica casts, but, in general, a spica cast begins at the chest and extends all the way down the fractured leg. The cast may also extend down the uninjured leg, or stop at the knee or hip. Your doctor will decide which type of spica cast is most effective for treating your child's fracture.

Your doctor will sedate your child for the closed reduction, and apply a spica cast immediately (or within 24 hours of hospitalization) to keep the fractured pieces in correct position until healing occurs.A thighbone fracture before and immediately after treatment with a spica cast. The femur will remodel over time so that it appears normal.

When a bone breaks and is displaced, the pieces often overlap and shorten the normal length of the bone. Because children's bones grow quickly, your doctor may not need to manipulate the pieces back into perfect alignment. While in the cast, the bones will grow and heal back into a more normal shape.

In general, for the best results, the broken pieces should not overlap more than 2 cm when in the cast. The growth of the thighbone may be temporarily increased by the trauma. The mild shortening from the overlap will resolve.

Traction. If the shortening of the bones is too much (more than 3 cm) or if the bone is too crooked in the cast, it may be helpful to put the leg in a weight and counterweight system (traction) to make sure the bones are properly realigned.Surgical Treatment

Doctors generally agree that displaced femur fractures that have shortened more than 3 cm are not acceptable and require treatment to correct at least a portion of the shortening.Left, Preoperative X-ray of a child with a fracture through the midshaft of the left femur. Right, Postoperative X-ray of the same child shows that the fracture was treated with internal flexible nailing to restore stability and allow early mobilization.

In some more complicated injuries, the doctor may need to surgically realign the bone and use an implant to stabilize the fracture.

Doctors are treating pediatric thighbone fractures more often with surgery than in previous years due to the benefits that have been recognized. These include earlier mobilization, faster rehabilitation, and shorter time spent in the hospital.

In children between 6 and 10 years old, flexible intramedullary (inside the bone) nails are often used to stabilize the fracture. Over the past decade, this treatment method has gained great acceptance.

Occasionally, the broken bone has too many pieces and can not be treated successfully with flexible nails. Other options that can lead to successful outcomes in this situation include:

* A plate with screws that "bridges" the fractured segments * An external fixator — this is often used if there has been a large open injury to the skin and muscles * Prolonged traction with a pin temporarily placed into the thighbone

External fixation is often used to hold the bones together when the skin and muscles have been injured.

As the child nears the teenage years (11 years to skeletal maturity), the most common treatment choices include either flexible intramedullary nails or a rigid locked intramedullary nail. The rigid nail is particularly useful when the fracture is unstable. Both types of nails allow for the child to begin walking immediately.A rigid, locked intramedullary nail is often used for femur fractures in adolescents who are nearly full grown.Top of pageLong-Term Outcomes

Generally, children who sustain a thighbone fracture will heal well, regain normal function, and have legs that are equal in length. The intramedullary nails may need to be removed following healing if they cause irritation of the skin and tissues underneath.

Occasionally, children will require further treatment, either early on or in subsequent years, if they have a significant difference in the length of the legs, unacceptable

angulation of the healed bone, abnormal rotation of the healed bone, infection, or (rarely) if a thighbone fracture persists (nonunion).

These problems can nearly always be resolved with further treatment.

Penatalaksanaan

Fratur batang femur diterapi menurut usia dan besar anak, seiringcedera ± cedera tersebut seperti cedera kepala atau politrauma, atautampak adanya lesi terbuka dengan cedera

pada pembuluh darah dan saraf.P

enyesuaian dengan pengobatan dan faktor sosioekonomik harusdipertimbangkan. (17)y 

Fraktur batang femur pada tahun pertama kehidupanP

ada periode postnatal, sebuah bandage sederhana atau harness digunakanuntuk panggul displastik diaplikasikan selama periode dari 2 minggu. Traksi bilateral overhead telah menjadi

pilihan pengobatan untuk selama beberapatahun. Anak yang dihospitalisasi selama 10 ± 14 tahun. Fraktur transversalrata ± rata sembuh dengan pemendekan (

 shortening ) beberapa millimeter.

Pada kasus kecurigaan cedera non accident, hospitalisasi memberikankesempatan untuk

menginvestigasi situasi sosial anak  

34y 

Fraktur batang femur pada usia 1 sampai 4 tahunTraksi masih digunakan secara luas untuk fraktur batang femur pada anak ± anak pra sekolah dan anak tahun pertama sekolah. Hospitalisasi selama

4 ± 6

 minggu dirasakan sudah memadai. Traksi kulit overhead (ov

erhead  

 skin 

traction) memiliki risiko berupa efek yang merugikan pada sirkulasiekstremitas. Traksi kulit sebaiknya dipilih bahan yang hipoalergenik (ex,Elastoplast) untuk pasien yang alergi dengan bahan yang biasa atau padaorang tua dimana kulitnya telah rapuh.Kontraindikasi traksi kulit yaitu bila terdapat

luka atau kerusakan kulit sertatraksi itu, itu, yang memerlukan beban > 5 kg. Akibat traksi kulit yangkelebihan beban di antaranya adalah nekrosis kulit, obstruksi vaskuler, oedemdistal,

serta peroneal nerve palsy pada traksi tungkaiy 

Fraktur batang femur pada usia 5 sampai 15 tahunDilakukan pemasangan Russel traksi, untuk traksi ini diperlukan : Frame,Katrol, Tali,

Plester. Anak tidur terlentang, lalu dipasang plester dari bataslutut, dipasang sling di daerah

poplitea, sling dihubungkan dengan tali, dimanatali tersebut dihubungkan dengan beban penarik. Untuk mempersingkat wakturawat setelah 4 minggu ditraksi, callus sudah terbentuk, tetapi belum kuat benar.

Traksi dilepas kemudian dipasang gip hemispika. Elastic 

intramedullar  ynail 

atau wayer Kirschner intramendular kadang digunakan untuk fraktur femur pada kelompok pra sekolah.Indikasi utama adalah gagalnya penanganan dengan menggunakan

 s pica 

cast.Titanium nail sberdiameter dua millimeter dimasukkan dari medialdan lateral metafisis

dari femur distal untuk menstabilisasi intramedular  pada fraktur. Waktu konsolidasi relative singkat, rentang waktu dari 2 ± 5 bulan tergantung pada usia pasien. Implant

dicabut pada 3 ± 6

bulansetelah pemasangan.

Konservatif Dilakukan pada anak-anak dan remaja dimana masih memungkinkan terjadinyapertumbuhan tulang panjang. Selain itu, dilakukan karena adanya infeksi ataudiperkirakan dapat terjadi infeksi. Tindakan yang dilakukan adalah dengan gips

dantraksi.o GipsG

ips yang ideal adalah yang membungkus tubuh sesuai denganbentuk tubuh. Indikasi dilakukan pemasangan gips adalah :

 

Immobilisasi dan penyangga fraktur 

Istirahatkan dan stabilisasi 

Koreksi deformitas 

Mengurangi aktifitas

 

Membuat cetakan tubuh orthotik Sedangkan hal-hal yang perlu diperhatikan

dalampemasangan gips adalah : G

ips yang pas tidak akan menimbulkan perlukaan G

ips patah tidak bisa digunakan G

ips yang terlalu kecil atau terlalu longgar sangat membahayakan klien J

angan merusak / menekan gips J

angan pernah memasukkan benda asing ke dalamgips / menggaruk 

  J

angan meletakkan gips lebih rendah dari tubuhterlalu lamao 

Traksi (mengangkat/menarik)Secara umum traksi dilakukan dengan menempatkan beban dengantali pada ekstermitas pasien. Tempat tarikan disesuaikan sedemikianrupa sehingga

arah tarikan segaris dengan sumbu panjang tulangyang patah.M

etode pemasangan traksi antara lain : 

Traksi manualTujuannya adalah perbaikan dislokasi, mengurangi fraktur,dan pada keadaan emergency

 

Traksi mekanik, ada 2 macam : 

Traksi kulit Dipasang pada dasar sistem skeletal untuk sturkturyang lain misal otot. Digunakan dalam waktu 4minggu dan beban < 5 kg.

 

Traksi skeletalM

erupakan traksi definitif pada orang dewasa yangmerupakan balanced traction. Dilakukan untuk menyempurnakan luka operasi dengan kawat metal /penjepit melalui tulang /

jaringan metal. 

Kegunaan pemasangan traksi, antara lain :  

Mengurangi nyeri akibat spasme otot 

 

Memperbaiki & mencegah deformitas

 

Immobilisasi 

Difraksi penyakit (dengan penekanan untuk nyeritulang sendi) 

Mengencangkan pada perlekatannya

 

Prinsip pemasangan traksi : 

Tali utama dipasang di pin rangka sehinggamenimbulkan gaya tarik  B

erat ekstremitas dengan alat penyokong harusseimbang dengan pemberat agar reduksi dapat dipertahankan

 

Pada tulang-tulang yang menonjol sebaiknya diberilapisan khusus 

Traksi dapat bergerak bebas dengan katrol

 

Pemberat harus cukup tinggi di atas permukaanlantai 

Traksi yang dipasang harus baik dan terasa nyaman 

Cara operatif/pembedahaPada saat ini metode penatalaksanaan yang paling banyak keunggulannya mungkin adalah pembedahan.

Metodeperawatan ini disebut fiksasi interna dan reduksi terbuka.Pada umumnya insisi

dilakukan pada tempat yangmengalami cedera dan diteruskan sepanjang bidanganatomik menuju tempat yang mengalami fraktur.

Hematoma fraktur dan fragmen-fragmen tulang yang telahmati diirigasi dari luka. Fraktur

kemudian direposisi dengantangan agar menghasilkan posisi yang normal kembali.Sesudah direduksi, fragmen-fragmen tulang ini

 dipertahankan dengan alat-alat ortopedik berupapen,sekrup,pelat,danpaku.Keuntungan

perawatan fraktur dengan pembedahan antaralain : 

Ketelitian reposisi fragmen tulang yang patah 

Kesempatan untuk memeriksa pembuluh darah dansaraf yang berada didekatnya 

Dapat mencapai stabilitas fiksasi yang cukupmemadai 

Tidak perlu memasang gips dan alat-alat stabilisasiyang lain 

Perawatan diR

S dapat ditekan seminimal mungkin,terutama pada kasus-kasus yang tanpa komplikasidan dengan kemampuan mempertahankan fungsisendi dan fungsi otot hampir

normal selamapenatalaksanaan dijalankan