Patients are positioned supine on a fracture table. The well leg is extended and slightly abducted to allow a true lateral fluoroscopic image of the fractured femur. Alternatively, a “well-leg” holder may be used. Provisional reduction to restore femoral length and rotation is obtained with boot traction and verified fluoroscopically (Fig. 10-1). Final alignment is performed with plate fixation, as described later.

A narrow 4.5-mm plate is most often used, as it is readily available, is easy to contour, and has percutaneous screw placement that is forgiving with the larger 4.5-mm screwheads. There are many plates now specifically designed for submuscular plating that utilizes both locking and nonlocking screws. Nonlocking screws achieve enough stability in this age group and allow easier percutaneous screw placement as compared with locking screws. Locking screws may benefit stability in osteopenic patients or in very proximal or distal fractures that have little available room for screws. If a locking plate is used, nonlocking screws are needed to reduce the femur to the precontoured plate. In addition, it may be easier to place the locking screws with direct plate exposure rather than percutaneous exposure. Self-tapping screws are essential for easier percutaneous insertion. In smaller children, a long, narrow, 3.5-mm plate may be used, though a 4.5-mm plate will fit most femurs, even in younger children.

The plate length chosen is usually 10 to 16 holes, depending on fracture location and patient size. The plate commonly spans from just below the greater trochanteric apophysis to the metaphysis of the distal femur. If possible, the plate length should allow three screws proximal and three screws distal to the fracture. A table plate bender contours the plate similar to the contour of the lateral femur, with a slight bend proximally and distally to accommodate the proximal and distal metaphysis. The final femoral varus/valgus alignment is the same as the plate, so it is important to contour the plate as close to anatomic as possible. Either a straight plate or plate with an anterior bow may be utilized depending on the sagittal alignment of the femur in traction and the implants available. The usual practice is to place the precontoured plate on the anterior thigh and then use the anteroposterior view on the C-arm to shadow the plate with the lateral femur cortex checking the contour (Fig. 10-2). Usually, there is no significant (greater than 5 degrees) misalignment as a result of incorrect contouring. There have been no reports of malunion in the sagittal plane.