On-line CEUs

Pediatric Femoral Shaft Fractures: Case #2
Phelo Keller, OTC

Available credit for this article: 1 CEU

The next child, a male age four, was playing at home when he tripped and fell injuring his right thigh. Deformity was noted and he was in severe pain.  He was transported to the emergency room where X-rays disclosed a femoral shaft fracture.  He was admitted for treatment of his injury.

The child’s mother was explained the alternative for treatment of the injury.  Also discussed was traction followed by immediate or delayed hip spica, as well as the surgical alternative.  In this case, external fixation would be the best surgical consideration. This procedure was explained to the mother with the relative advantages and disadvantages over more conservative treatment.  External fixation was recommended for consideration.  The physician emphasized that this is not a risk free treatment.  There is relatively high incident of pin-track infection.  He also emphasized the fact that the fixator may need to be adjusted during treatment to correct deterioration of position.  Although the fixator would allow the patient to leave the hospital early, he would still be essentially restricted to bed rest during the healing phase and require intensive care at home. The mother accepted the fixator treatment. Skin detraction to the right leg was applied until surgery.

Operative Procedure in Detail
The child was administered a general anesthesia and positioned on a radio lucent table with C-arm draped for monitoring the procedure.  Initially, a closed reduction was performed and verified with C-arm imagery. The first pin was inserted from the lateral thigh percutaneously just distal to the lesser rotator on the medial cortex. This pin was pre-drilled and then inserted in the usual fashion.  The external fixator was loosely erected on this first pin and used as a jig for placement of other pins.  The most distal pin site was selected, stab incision made, and a blunt dissection down to the bone was carried out.  The drill guide was inserted and the hole was pre-drilled and the pin inserted.  The second proximal pin was inserted in a similar fashion and then the distal in board pin was inserted.  Reduction was again carried out and checked with the C-arm image and AP and lateral views.  Good reduction was achieved with approximately 1 centimeter override at the fracture site to account for laid overgrowth.  The fixator was tightened with the fracture in this position.  Pin sites were dressed with Iodoform gauze and large fluff dressings were applied about the fixator.  The knee was placed in extension and a posterior plaster splint applied to the ankle.  The patient left the operating room in satisfactory condition (picture 1).

One week post discharge, x-rays showed good position of this fracture with 1 centimeter override.  The dressing contained a small amount of drainage from the proximal pins.  A new dressing and a new posterior splint was applied for the knee.  Antibiotics were started and a refill of pain medicine was given. After about two weeks, his proximal pins looked no worse.  There was still some slight drainage.  The mother states that she has to watch him closely to prevent him from standing and walking.  X-rays showed good callus formation with no change in position. His return visit is in two weeks (picture 2).

Four days after his last visit, some bleeding was noted around his proximal bandages. There were no changes,  but some drainage around the proximal pins.   At one month post-fracture, the child complained of pain around his knee.  Overall he seems to be doing well.  X-rays showed more callus, and on his next visit removal of the external fixator may be scheduled.  The next visit revealed prominent callus formation and his pins site looked good.  He was scheduled for external fixation removal within two weeks (picture 3).

Operative Procedure in Detail For Removal of External Fixator
The child was given general anesthesia and when adequately reduced, the external fixator apparatus was removed from the percutaneous pins with the appropriate Allen wrench. Each pin was then removed using a hand chuck.  Some inflammation around the pins was noticed, but there was no drainage present.  The fracture was solidly healed on x-ray, and this was confirmed on exam under anesthesia.  Ninety-degree flexion was achieved in gradual and gentle fashion.  The pins sites were sterilely prepped and dressing applied. The child left the operating room in good condition.

Three weeks after the removal of the fixator, the patient’s knee was quite stiff.  It was manipulated by the physician.  At follow up, he walked without much of a limp.  Range of motion was discussed.  His pin tracts were healing well.  Follow up x-rays looked good and the patient was released from treatment.  It was emphasized that he should keep activities restricted for at least another month.

References:
Charles A. Rockwood, “Fractures in Children”

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