The patient is positioned supine on a fracture table, which helps obtain a provisional reduction. The fracture table can be a useful aid in reduction. However, it is important to note that use of the fracture table in pediatric femur fracture treatment has been linked to a 3.1% nerve palsy incidence. While most these cases completely resolved, it is recommended that the surgeon should attempt to minimize the time the leg is in traction.¹² Length and rotation are obtained with the traction; final alignment can be performed with the plate fixation described later. Once the patient is positioned on the fracture table, the unaffected leg is extended carefully and abducted, which allows the ability to obtain a true lateral fluoroscopic image of the femur for screw placement. Alternatively, the unaffected leg may be flexed on a well-leg holder. A radiolucent table without traction may be used if adequate assistance is available to maintain traction. Care must be taken while obtaining provisional fixation to account for rotation. In comminuted fractures, rotation is the most difficult parameter to assess.

In our initial description of the procedure, my colleagues and I recommended a long, narrow 4.5-mm plate.¹¹ This plate is readily available and is easy to contour, and percutaneous screw placement is forgiving. Currently, many manufacturers offer pediatric submuscular femoral plates; some include an anterior bow and locking technology. The specific plate chosen is based on the surgeon’s preference. Locking plate technology may be most important in osteopenic patients or in very proximal or distal fractures, where little room is available for screws. In my experience, a nonlocking stainless steel plate achieves enough stability in pediatric patients. In the series we reported, no plate failures or nonunions were noted.¹³ The locking plate may require a longer surgical time because percutaneous screw placement is less forgiving with percutaneous application. Using nonlocking screws assists in the reduction of the fracture. Therefore, if a locking plate is used, a combination of locking and nonlocking screws is needed to reduce the femur to the contoured plate. Percutaneous
screw fixation is easier with 4.5-mm self-tapping screws because the screw heads are larger, and a 4.5-mm plate has the advantage of stronger fixation. In smaller children, a long, narrow 3.5-mm plate may be used; however, a 4.5-mm plate fits most femurs.

The plate length chosen will have approximately 10 to 16 holes, and the length will vary with fracture location and patient size. The plate commonly spans from just below the greater trochanteric apophysis to the metaphysis of the distal femur. The plate should be long enough to accommodate three screws proximal to and three screws distal to the fracture; however, in a proximal or a distal fracture, two screws may be adequate, particularly if they are locking screws. A table plate bender is used to contour the plate to the lateral femur with a slight bend proximally and distally to accommodate the proximal and distal metaphyses. It is important to note that the final femoral varus/valgus alignment will match that of the plate; thus, it is critical to contour the plate as close to the native anatomy of the lateral femur as possible. The usual method of checking the contour is to place the precontoured plate on the anterior thigh and use the AP view on the C-arm to shadow the lateral cortex. The contralateral femur also may be used as a template. In my experience, no significant (>5°) malalignment has occurred as a result of misjudged contouring.

A 3- to 5-cm incision is made over the distal lateral thigh through the tensor fascia to expose the distal obliquely oriented fibers of the vastus lateralis muscle (Figure 2, A). Blunt dissection is performed deep to the distal muscle fibers to dissect the plane between the vastus lateralis and the periosteum of the lateral femur (Figure 2, B and C). Then the plate is slowly tunneled proximally in this plane (Figure 3, A through C). Care is taken to keep the plate on the lateral femur as it is advanced proximally past the fracture to the region of the greater trochanteric apophysis. The plate may be more difficult to pass along the lateral femur past the fracture. The surgeon may correct this by pulling the plate back and redirecting it. The C-arm also may aid the surgeon in plate advancement (Figure 3, D through H).

Once the plate is fully advanced, it should sit comfortably on the lateral femur. AP and lateral images are obtained to ensure that the plate is in good position in both planes and that the femoral length is restored. The plate is provisionally fixed to the femur with 2-mm Kirschner wires (K-wires) placed in the most proximal and distal screw holes (Figure 4). If the fracture is “sagging” in the lateral plane, the femur can be lifted in an anterior direction while a K-wire is placed through the plate to engage the femur in this region. A K-wire also can be used to adjust the anterior-posterior position of the plate on the lateral image (Figure 4, B). A long plate and correct screw placement are important for construct stability. The principle of pin placement in external fixation is used for screw placement. One screw should be placed close to both the proximal and distal limits of the fracture. The remaining screws are spread as far apart as possible because maximal screw spread improves construct stability. Three screws proximal to and three screws distal to the fracture are recommended. Occasionally, there may be room for only two screws in the very proximal and distal fracture; this may still be adequate with a long plate or adjunctive use of locking screws. The first screw should be placed where the femur is farthest from the plate, thus acting as a reduction screw. As the screw engages the far cortex, the femur will be reduced to the precontoured plate (Figure 5). The fracture is “bridged,” and no attempt is made to place a screw across the fracture fragments, nor is the fracture exposed; the soft-tissue sleeve is left undisturbed around the fracture.

Accurate percutaneous screw placement is obtained as follows. Screws are placed using the “perfect circles” technique. Using a fluoroscopic image in the lateral plane,
a No. 15 blade is placed on the skin over the hole and rotated horizontal to the beam through the skin, tensor fascia, and vastus fascia. Using a freehand technique, a 3.2-mm drill is placed in this small incision, and its location in the desired hole is confirmed with fluoroscopy. The hole is then drilled through both cortices. The length of the screw is approximated by placing the depth gauge on the anterior thigh as the image is rotated to
the AP view to obtain the approximate screw length. A 0 Vicryl suture (Ethicon) is tied around the 4.5-mm fully threaded cortical screw head so it will not be lost in the soft tissue. The screw is then placed through the plate and across the femur. As the screw engages the femur, it will reduce the femur to the precontoured plate (Figure 6). The Vicryl ties are cut and the incisions are closed. A soft dressing is applied.