Children 5 to 12 years old (younger or older child is not a true contraindication)

 Length-stable fractures with minimum or no comminution

 Middle 70% of the diaphysis

 Weight less than 50 kg

 A thorough physical examination is conducted.

 Good-quality anteroposterior (AP) and lateral radiographs of the femur are required for diagnosis and planning.

• Figure 1 shows AP (Fig. 1A) and lateral (Fig. 1B) radiographs of a mid-diaphyseal femur fracture.

• Radiographs should include one joint above and below the fracture.

 A computed tomography scan may help in complex fracture patterns and to identify other associated injuries such as stress fracture or intra-articular injuries.

 The distal femoral physis is marked under fluoroscopy to avoid any inadvertent injury to the physis.

 The popliteal vessels and the nerve are posterior to the femur at the surgical site (Fig. 2). Avoid slippage of the drill posteriorly while drilling the lateral and medial holes.

 The patient is positioned supine on a radiolucent table or a fracture table (our preference).

 Smaller children (usually < 8 years old) may be better positioned on a radiolucent table, while bigger children (>8 years old) are best positioned on a fracture table.

 On the fracture table, the foot of the affected extremity is placed in the foot holder attached to the traction device.

• The affected leg is abducted 15–30°, allowing working on both sides of the femur (Fig. 3).

• The white arrow between the legs in Figure 3 depicts the position of the image intensifier.

 The unaffected foot is placed in a similar foot holder with the hip in extension (scissor position of the well leg) or 15° of abduction. Due to reports of compartment syndrome, we avoid positioning the unaffected leg in a flexed, abducted position of the hip over the patient.

 If it is not possible to place traction through the foot of the affected extremity, a traction pin may be inserted in the proximal tibia.

 Two 2-cm incision are made medially and laterally over the distal femoral physis.

 After adequate positioning of the patient on a fracture table, the fracture is reduced as best as possible. The leg is prepared and draped in a standard manner either on the fracture table or on a radiolucent table.

 The distal femoral physis is identified under an image intensifier (Fig. 4), and the nail entry sites are marked 2 cm proximal to the physis on the medial and lateral distal femoral metaphyses.

Related posts:

41: Operative Treatment of Tillaux Fractures of the Ankle 7: Forearm Fractures: Closed Treatment 32: Patellar Instability: Lateral Release and Medial Plication 1: Modified Woodward Procedure for Sprengel’s Deformity 47: Resection of Calcaneonavicular Coalition and Fat Autograft Interposition 60: Thoracoscopic Release and Instrumentation for Scoliosis

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