Submuscular Plating of Femoral Fracture

Indications

Subtrochanteric, diaphyseal, distal metadiaphyseal femoral fracture
Length unstable fracture pattern (comminuted, long oblique, butterfly fragment)
Ages: 5 to 11

Patient Positioning

Supine on the radiolucent fracture table with legs scissored (Figure 21-22).
- Bump underneath ipsilateral buttocks to prevent patient external rotation
- Contralateral leg lower to aid in radiographic lateral imaging
- Ipsilateral arm across chest over pillow to clear operative side
- Avoid malrotation by placing the hip and the knee cap to the ceiling. Look longitudinally from the foot and the limb position of the anterior hip and anterior knee should match. Significant internal or external rotation of the foot and the distal fracture should be a cause of concern and reevaluation.
Complete fluoroscopic AP and lateral views at the hip, fracture, and knee to assure ability to visualize femur completely and obtain provisional reduction

Surgical Approaches

In general, proximal exposure with placing plate from proximal to distal is best for subtrochanteric fractures as well as proximal third shaft fracture
- Incision (3 cm) centered over the lateral femur distal to horizontal line from tip of trochanter
- Split IT band and make a reverse L-shaped incision on the vastus ridge to lift up 2 cm of vastus above periosteum to gain access to beginning of tunneling track. The optimal plate will end matching the lateral flare of the femur just distal to greater troch.
Fractures in the mid-diaphyseal region and below should be fixed by placing a plate from distal to proximal (Figure 21-23)
- Incision is direct lateral starting 1 cm distal to distal femoral physis and extending proximally
- Split IT band longitudinally and the distal insertion of vastus lateralis is found. Lift up the distal end of the vastus and coagulate perforating vessels. This will extraperiosteally expose distal femoral lateral cortex and should be done proximal to femoral physis and subvastus but extraperiosteal.

Figure 21-22 ▪ Fracture table positioning with legs scissored.

Reduction and Fixation Techniques

Plate length should be long and extend from insertional flare to just short of the opposite flare (Figure 21-24).
- Proximally inserted plates should have a length and contour that ends above distal metaphyseal flare and matched the proximal flare of the femur below the trochanteric region.
- Distally inserted plates should be inserted ending just short of flare of proximal femur and should be contoured to match the distal metaphyseal flare above the physis.
Prior to placing plate, use a Cobb elevator to create subvastus and extraperiosteal tunnel up to (or down to) fracture. Maintain extraperiosteal plane.

Connect the locking screw guide to the plate at most proximal (if proximal insertion) or distal hole to help with pushing the plate (Figure 21-25).Use fluoroscopic guidance to make sure the plate is tunneling correctly. The plate should remain in perfect profile going parallel up the femur and if you are losing profile then malrotation of the plate is occurring or anterior or posterior misdirection is occurring (Figure 21-26).