Options by age:
0-4 years – early hip spica or hip spica after traction; external fixation
4-10 years – flexible nail, external fixation, maybe hip spica
>10 years – flexible nails, external fixation, IM nail
What is acceptable with closed treatment? These are argued, and the references all quote different numbers. Most agree that rotation is not acceptable.
– no rotation – this will not correct
– 10-15 mm of shortening – will probably correct to a certain degree with overgrowth
– 10 degrees of varus or valgus (some say 15)
– 15 degrees of flexion or extension (some say 20)
You have to use your head – obviously, at a very young age, you could probably accept the upper limit, but at an older age, you better get it pretty close.
– has to be pretty straightforward fracture without excessive shortening – the cast will not correct shortening.
– should try to get it perfect on initial reduction
– initial traction for 10-21 days and waiting until it shows some callus is the other technique and is the bail-out if you don’t think the shortening is acceptable.
– again, different authors describe different amounts of this phenomenon
– some say age has nothing to do with it, others think it is more prominent in the 8-10 year old range
– others say that overgrowth of the femur is about 1 cm, and of the tibia is about 3 mm. Shapiro thinks that it is independent of age, level of fracture, or position of the fracture at time of healing (short, long, or distracted). Others say that the overgrowth is proportional to shortening at healing.
– it is probably a vascular phenomenon to the entire leg
– in the final analysis, shortening of 1 to 1.5 cm is probably acceptable in closed treatment.
Beware putting flexible nails up through an open fracture – in adults, probably okay, but in kids, it has not yet been sorted out. Better to just go with external fixation.
Do not do a standard locked IM nail until the kid’s proximal femoral physis is closed. You better be pretty wary about doing it even then – the consequences of AVN are just so devastating.
Indications for ORIF
– floating knee
– head trauma (they get spasticity which is hard to deal with in a cast)