PROCEDURE 28

Femur Fracture

Closed Reduction and Spica Cast

Matthew Diltz and Mininder S. Kocher

Indications

 Closed fracture of the femoral shaft

 Children less than 6 years old

Pitfalls

• Reviews of the outcomes for treatment of femoral fractures with spica cast have demonstrated poor outcome in children older than 6–8 years and greater than 100 pounds.

• Additional contraindications include open fractures, ipsilateral tibia fractures, and abdominal and head trauma.

Examination/Imaging

 As with any case of trauma, it is important to evaluate the entire patient.

 The neurovascular status of the extremity should be documented

• Vascular injuries are not uncommon with femur fractures in children

 The location of the fracture on radiographs in relation to the shaft of the femur influences external treatment and the method of reduction.

 The radiograph should be reviewed carefully for any signs of bone tumor.

 If there is any indication of child abuse, a bone survey looking for additional fractures in various stages of healing can be ordered.

Treatment Options

• Pavlik harness in children less than 6 months

• Flexible nails

• External fixation

• Submuscular plating

• Intramedullary nail

Anatomy

 In order to perform the appropriate reduction and mold the cast, it is important to remember the muscles forces acting on the fracture.

• Proximal-third fractures can be hard to maintain. The proximal fragment tends to be abducted and flexed by the insertion of the muscles at the trochanters.

• Middle-third fractures tend to fall into varus and external rotation. A valgus mold is important to resist this deformity.

• For fractures of the distal third of the femur, the gastrocnemius tends to pull the fracture into recurvatum. Flexing the knee takes tension off the muscle and helps to maintain the reduction.

Positioning

 The patient is placed supine on a radiolucent table (Fig. 1A and 1B).

 A spica table is prepared with padding of the central perineal post (Fig. 2).

 The position of the leg is dependent on the location of the fracture. General guidelines for leg positioning are as follows:

• Proximal-third fractures

 Hip flexion: 45°

 Hip abduction: 30°

 External rotation: 20°

• Midshaft fractures

 Hip flexion: 30°

 Hip abduction: 20°

 External rotation: 15°

• Distal-third fractures

 Hip flexion: 20°

 Hip abduction: 20°

 External rotation: 15°

Pitfalls

• Too much abduction can result in increased pressure at the femoral head and lead to avascular necrosis of the femoral head.

Equipment

• Radiographs demonstrating the fracture

• Pediatric spica table

• Fluoroscopy

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