AO Surgery Reference

Pediatrics

(Femoral Shaft)

Definitions & Classification

( Zaky Ortho )

1. 32-D/4.1 Complete transverse, simple

2. 32-D/5.1 Complete oblique or spiral, simple
3. 32-D/4.2 + 5.2 Multifragmentary
32-D/4.1 Complete transverse, simple
Definition
Simple transverse or oblique (≤30°) fractures of the femoral shaft are classified 32-
D/4.1. They may occur in the proximal, middle, or distal third of the femoral shaft.

These fractures are often a result of high-energy trauma.

They are axially stable and do not tend to shorten under load.

X-ray
32-D/5.1 Complete oblique or spiral,
simple
Definition
Simple oblique (>30°) or spiral fractures of the femoral shaft are classified 32-
D/5.1. They may occur in the proximal, middle, or distal third of the femoral shaft.

These fractures are often a result of trauma with a rotational force.

They are axially unstable.

X-ray
Oblique middle-third fracture
Long oblique proximal-third fracture
32-D/4.2 + 5.2 Multifragmentary
Definition
Multifragmentary femoral shaft fractures can be segmental transverse (32-D/4.2) or
...

... wedge, oblique segmental, or comminuted (32-D/5.2). They may occur in the
proximal, middle, or distal third of the femoral shaft.

These fractures are often a result of higher-energy trauma such as motor-vehicle

crashes.

They are axially unstable.

X-ray
Multifragmentary fracture in an 11-year-old female

4-year-old child, isolated multifragmentary femoral shaft fracture

Multifragmentary spiral fracture
 AO Surgery Reference

Pediatrics

(Femoral Shaft)

Treatment Options
( Zaky Ortho )

1. 32-D/4.1 Complete transverse, simple

2. 32-D/5.1 Complete oblique or spiral, simple
3. 32-D/4.2 + 5.2 Multifragmentary
32-D/4.1 Complete transverse, simple
The treatment of femoral shaft fractures in children is determined by the age and
size/weight of the child.

In the younger child, there is a potential for substantial modeling and conservative
management is often suitable.

If the use of a traction pin is thought to be necessary in an older, heavier child,

careful consideration should be given to operative fixation as both will require a
general anesthetic.

Operative management is often necessary in the older children due to higher energy
of injury, with complex fracture patterns that tend to be less stable.

The implant choice depends on the characteristics of the fracture, local preferences
and available expertise.

Pavlik harness

Main indications:

Any fracture pattern in children up to 3 months of age

Contraindications
Extremes of weight

Advantages
No sedation or anesthesia needed

Disadvantages
Risk of femoral nerve compression with excessive hip flexion and swollen thigh

Hip spica casting

Main indications:

Any fracture pattern in children up to 4 years of age

Relative contraindications
Polytrauma
Open fractures
Shortening of more than 2–3 cm

Disadvantages
Risk of compartment syndrome
Risk of loss of reduction
Risk of pressure sores

Traction with delayed spica casting

Main indications:

Any fracture pattern in children from 3 months up to 4 years of age (depending

on body size/weight), if immediate spica casting unavailable

This treatment option may be used for older patients if resources are limited.

Further indications
Significant shortening

Advantages
Restoration of length
Fracture is beginning to heal and spica may be applied without general anesthetic

Disadvantages
Length of stay
Risk of compartment syndrome
Risk of loss of reduction
Risk of pressure sores
Traction

Main indications:

Initial treatment prior to definitive surgery, definitive treatment for any fracture
pattern in any age (if surgical fixation is not available), patient too heavy for spica
casting

Further indications
Significant shortening

Contraindications
Open fractures
Polytrauma

Advantages
Appropriate alternative if resources limited

Disadvantages
Risk of malunion
Prolonged hospital stay
Complications of recumbency
Insertion of traction pin requires general anesthetic
Risk of growth plate injury with skeletal traction pin
Risk of pin-track infection
Muscle wasting
Risk of pressure sores

ESIN (retrograde)
Main indications:

Shaft fractures of the middle and proximal third in children from 4 up to 12–13
years of age (depending on body size/weight)

Advantages
Short stay
Minimally invasive
Relatively inexpensive implant

Disadvantages
Increased risk of malunion with increasing age and weight of patient
Risk of pain at insertion site

ESIN (antegrade)

Main indications:

Shaft fractures of the distal third in children from 4 up to 12–13 years of age
(depending on body size/weight)

Advantages
Short stay
Minimally invasive
Relatively inexpensive implant

Disadvantages
Increased risk of malunion with increasing age and weight of patient
Risk of pain at insertion site
Risk of iatrogenic stress fracture at entry points

Locked nailing with lateral trochanteric entry

Main indications:

Children of 10–16 years of age (depending on medullary canal diameter and on

body size/weight)

Lateral trochanteric entry is required if the proximal femoral growth plate is open,
to avoid avascular necrosis of the femoral head.

Further indications
Multifragmentary fractures
Polytrauma
Pathological fractures

Contraindications
Medullary canal too narrow

Advantages
Good control of length and rotation
Early mobilization

Disadvantages
Risk of avascular necrosis with improper technique/implant

External fixation

Main indications:

Polytrauma, multiple fractures, open fractures, burns, head injuries

External fixation is typically used in clinical situations where internal fixation or
cast treatment are contraindicated due to patient, injury, or fracture
characteristics. It may be used temporarily or for definitive treatment.

Advantages
Image intensifier not essential, but useful
Rapid application
Can be converted to definitive internal fixation

Disadvantages
High risk of pin-track infection
Higher rates of delayed union, nonunion, and malunion
Increased risk of refracture after removal of fixator
Knee stiffness

MIPO

Main indications:

Proximal or distal fractures (if alternatives not available)

Plating is rarely indicated in children under 5 years of age.

Bridge plating is an alternative to flexible nailing for length unstable fractures. If

a locked nail large enough for the femur is available it may be preferable to
bridge plating in an older child.

Further indications
Length unstable fractures
Polytrauma

Advantages
Good control of length and rotation

Disadvantages
Technically demanding
Image intensifier required
Slow union
Implant removal
Risk of refracture following implant removal
Scarring
Open reduction; plate fixation

Main indications:

Proximal or distal fractures (if alternatives not available)

Plating is rarely indicated in children under 5 years of age.

Bridge plating is an alternative to flexible nailing for length unstable fractures. If

a locked nail large enough for the femur is available it may be preferable to
bridge plating in an older child.

Further indications
No image intensifier available

Advantages
Good control of length and rotation

Disadvantages
Technically demanding
Slow union
Implant removal
Risk of refracture following implant removal
Scarring
32-D/5.1 Complete oblique or spiral,
simple
The treatment of femoral shaft fractures in children is determined by the age and
size/weight of the child.

In the younger child, there is a potential for substantial modeling and conservative
management is often suitable.

If the use of a traction pin is thought to be necessary in an older, heavier child,

careful consideration should be given to operative fixation as both will require a
general anesthetic.

Operative management is often necessary in the older children due to higher energy
of injury, with complex fracture patterns that tend to be less stable.

The implant choice depends on the characteristics of the fracture, local preferences
and available expertise.

Simple oblique or spiral fractures may be length unstable.

Pavlik harness

Main indications:

Any fracture pattern in children up to 3 months of age

Contraindications
Extremes of weight

Advantages
No sedation or anesthesia needed

Disadvantages
Risk of femoral nerve compression with excessive hip flexion and swollen thigh
Hip spica casting

Main indications:

Any fracture pattern in children up to 4 years of age

Relative contraindications
Polytrauma
Open fractures
Shortening of more than 2–3 cm

Disadvantages
Risk of compartment syndrome
Risk of loss of reduction
Risk of pressure sores

Traction with delayed spica casting

Main indications:

Any fracture pattern in children from 3 months up to 4 years of age (depending

on body size/weight), if immediate spica casting unavailable

This treatment option may be used for older patients if resources are limited.

Further indications
Significant shortening

Advantages
Restoration of length
Fracture is beginning to heal and spica may be applied without general anesthetic

Disadvantages
 Length of stay
Risk of compartment syndrome
Risk of loss of reduction
Risk of pressure sores

Traction

Main indications:

Initial treatment prior to definitive surgery, definitive treatment for any fracture
pattern in any age (if surgical fixation is not available), patient too heavy for spica
casting

Further indications
Significant shortening

Contraindications
Open fractures
Polytrauma

Advantages
Appropriate alternative if resources limited

Disadvantages
Risk of malunion
Prolonged hospital stay
Complications of recumbency
Insertion of traction pin requires general anesthetic
Risk of growth plate injury with skeletal traction pin
Risk of pin-track infection
Muscle wasting
Risk of pressure sores

ESIN (retrograde)
Main indications:

Shaft fractures of the middle and proximal third in children from 4 up to 12–13
years of age (depending on body size/weight)

In highly length unstable fractures sometimes this technique may not be suitable.

To provide stability in these unstable fractures end caps are strongly

recommended.

Advantages
Short stay
Minimally invasive
Relatively inexpensive implant

Disadvantages
Increased risk of malunion with increasing age and weight of patient
Risk of pain at insertion site

ESIN (antegrade)

Main indications:

Shaft fractures of the distal third in children from 4 up to 12–13 years of age
(depending on body size/weight)

In highly length-unstable fractures sometimes this technique may not be suitable.

To provide stability in these unstable fractures end caps are strongly
recommended.

Advantages
Short stay
Minimally invasive
Relatively inexpensive implant

Disadvantages
Increased risk of malunion with increasing age and weight of patient
Risk of pain at insertion site
Risk of iatrogenic stress fracture at entry points

Locked nailing with lateral trochanteric entry

Main indications:

Children of 10–16 years of age (depending on medullary canal diameter and on

body size/weight)

Lateral trochanteric entry is required if the proximal femoral growth plate is open,
to avoid avascular necrosis of the femoral head.

Further indications
Multifragmentary fractures
Polytrauma
Pathological fractures

Contraindications
Medullary canal too narrow

Advantages
Good control of length and rotation
Early mobilization

Disadvantages
 Risk of avascular necrosis with improper technique/implant

External fixation

Main indications:

Polytrauma, multiple fractures, open fractures, length-unstable factures (if

alternatives not available), burns, head injuries

External fixation is typically used in clinical situations where internal fixation or

cast treatment are contraindicated due to patient, injury, or fracture
characteristics. It may be used temporarily or for definitive treatment.

Advantages
Image intensifier not essential, but useful
Rapid application
Can be converted to definitive internal fixation

Disadvantages
High risk of pin-track infection
Higher rates of delayed union, nonunion, and malunion
Increased risk of refracture after removal of fixator
Knee stiffness

MIPO

Main indications:

Length-unstable fractures, proximal or distal fractures (if alternatives not

available)

Plating is rarely indicated in children under 5 years of age.

Bridge plating is an alternative to flexible nailing for length unstable fractures. If

a locked nail large enough for the femur is available it may be preferable to
bridge plating in an older child.

Further indications
Polytrauma

Advantages
Good control of length and rotation

Disadvantages
Technically demanding
Image intensifier required
Slow union
Implant removal
Risk of refracture following implant removal
Scarring

Open reduction; plate fixation

Main indications:

Length-unstable fractures, proximal or distal fractures (if alternatives not

available)

Plating is rarely indicated in children under 5 years of age.

Bridge plating is an alternative to flexible nailing for length unstable fractures. If

a locked nail large enough for the femur is available it may be preferable to
bridge plating in an older child.

Further indications
No image intensifier available

Advantages
Good control of length and rotation

Disadvantages
Technically demanding
Slow union
Implant removal
Risk of refracture following implant removal
Scarring
32-D/4.2 + 5.2 Multifragmentary
The treatment of femoral shaft fractures in children is determined by the age and
size/weight of the child.

In the younger child, there is a potential for substantial modeling and conservative
management is often suitable.

If the use of a traction pin is thought to be necessary in an older, heavier child,

careful consideration should be given to operative fixation as both will require a
general anesthetic.

Operative management is often necessary in the older children due to higher energy
of injury, with complex fracture patterns that tend to be less stable.

The implant choice depends on the characteristics of the fracture, local preferences
and available expertise.

The more fragmented and the more oblique the fracture lines are the less length
stable is the fracture zone.

Pavlik harness

Main indications:

Any fracture pattern in children up to 3 months of age

Contraindications
Extremes of weight

Advantages
No sedation or anesthesia needed

Disadvantages
Risk of femoral nerve compression with excessive hip flexion and swollen thigh

Hip spica casting

Main indications:

Any fracture pattern in children up to 4 years of age

Relative contraindications
Polytrauma
Open fractures
Shortening of more than 2–3 cm

Disadvantages
Risk of compartment syndrome
Risk of loss of reduction
Risk of pressure sores

Traction with delayed spica casting

Main indications:

Any fracture pattern in children from 3 months up to 4 years of age (depending

on body size/weight), if immediate spica casting unavailable

This treatment option may be used for older patients if resources are limited.

Further indications
Significant shortening

Advantages
Restoration of length
Fracture is beginning to heal and spica may be applied without general anesthetic

Disadvantages
Length of stay
Risk of compartment syndrome
Risk of loss of reduction
Risk of pressure sores
Traction

Main indications:

Initial treatment prior to definitive surgery, definitive treatment for any fracture
pattern in any age (if surgical fixation is not available), patient too heavy for spica
casting

Further indications
Significant shortening

Contraindications
Open fractures
Polytrauma

Advantages
Appropriate alternative if resources limited

Disadvantages
Risk of malunion
Prolonged hospital stay
Complications of recumbency
Insertion of traction pin requires general anesthetic
Risk of growth plate injury with skeletal traction pin
Risk of pin-track infection
Muscle wasting
Risk of pressure sores

ESIN (retrograde)
Main indications:

Shaft fractures of the middle and proximal third in children from 4 up to 12–13
years of age (depending on fracture configuration and body weight)

In highly length unstable or comminuted fractures sometimes this technique may

not be suitable.

To provide more stability in these unstable fractures end caps are strongly
recommended.

Advantages
Short stay
Minimally invasive
Relatively inexpensive implant

Disadvantages
Increased risk of malunion with increasing age and weight of patient
Risk of pain at insertion site

ESIN (antegrade)

Main indications:

Shaft fractures of the distal third in children from 4 up to 12–13 years of age
(depending on body size/weight)

In highly length unstable or comminuted fractures sometimes this technique may

not be suitable.

To provide stability in these unstable fractures end caps are strongly

recommended.

Advantages
Short stay
Minimally invasive
Relatively inexpensive implant
Disadvantages
Increased risk of malunion with increasing age and weight of patient
Risk of pain at insertion site
Risk of iatrogenic stress fracture at entry points

Locked nailing with lateral trochanteric entry

Main indications:

Children of 10–16 years of age (depending on medullary canal diameter and on

body size/weight)

Lateral trochanteric entry is required if the proximal femoral growth plate is open,
to avoid avascular necrosis of the femoral head.

Further indications
Multifragmentary fractures
Polytrauma
Pathological fractures

Contraindications
Medullary canal too narrow

Advantages
Good control of length and rotation
Early mobilization

Disadvantages
Risk of avascular necrosis with improper technique/implant

External fixation
Main indications:

Polytrauma, multiple fractures, open fractures, length-unstable factures (if

alternatives not available), burns, head injuries

External fixation is typically used in clinical situations where internal fixation or

cast treatment are contraindicated due to patient, injury, or fracture
characteristics. It may be used temporarily or for definitive treatment.

Advantages
Image intensifier not essential, but useful
Rapid application
Can be converted to definitive internal fixation

Disadvantages
High risk of pin-track infection
Higher rates of delayed union, nonunion, and malunion
Increased risk of refracture after removal of fixator
Knee stiffness

MIPO

Main indications:

Length-unstable fractures, proximal or distal fractures (if alternatives not

available)

Plating is rarely indicated in children under 5 years of age.

Bridge plating is an alternative to flexible nailing for length unstable fractures. If

a locked nail large enough for the femur is available it may be preferable to
bridge plating in an older child.

Further indications
Polytrauma
Advantages
Good control of length and rotation

Disadvantages
Technically demanding
Image intensifier required
Slow union
Implant removal
Risk of refracture following implant removal
Scarring

Open reduction; plate fixation

Main indications:

Length-unstable fractures, proximal or distal fractures (if alternatives not

available)

Plating is rarely indicated in children under 5 years of age.

Bridge plating is an alternative to flexible nailing for length unstable fractures. If

a locked nail large enough for the femur is available it may be preferable to
bridge plating in an older child.

Further indications
No image intensifier available

Advantages
Good control of length and rotation

Disadvantages
Technically demanding
Slow union
Implant removal
Risk of refracture following implant removal
Scarring
 AO Surgery Reference

Pediatrics

(Femoral Shaft)

Treatments
( Zaky Ortho )

1. Pavlik harness
2. Hip spica casting
3. Traction with delayed spica casting
4. ESIN (retrograde)
5. Traction
6. ESIN (antegrade)
7. MIPO
8. Open reduction; plate fixation
9. External fixation
10. Locked intramedullary nailing (ALFN)
Pavlik harness
1. General considerations
The Pavlik harness can be used for femoral fractures in infants up to 3 months of
age.

The principle is to splint the limb for comfort. Periosteal healing and modeling are
rapid and reliable at this age.

Reduction of the fracture is not necessary.

2. Size of the harness

Measure the diameter of the infant’s chest at the nipple line and select a harness of
appropriate size.
3. Application
Open the chest and shoulder straps and lie the opened harness on the table.

Place the infant on top of the harness.

Close the chest strap at nipple level allowing a two-finger space below the strap.

Attach the shoulder straps to keep the chest strap in position.

Remove the foot stirrups and place each foot into a stirrup.

Reattach the anterior strap to the medial buckle of the foot stirrup and adjust the
length to produce 90° hip flexion.
Reattach the posterior strap to the lateral buckle of the foot stirrup. Do not
overtighten the strap. Allow for full abduction and for adduction to neutral.

Mark the strap lengths to allow easier reapplication of the harness.

4. Aftercare
The harness can be left on full time for approximately two weeks until the fracture
is comfortable with early callus.
Hip spica casting
1. General considerations

Single-leg, one-and-a-half-leg, or two-leg spica

Whilst a single-leg spica is adequate for most circumstances; some surgeons prefer
to extend the cast to the uninjured side as this can help to provide more stability,
especially in young children.

Complications
Loss of reduction
Compartment syndrome
Pressure sore

Note on illustrations

Throughout this section generic fracture patterns are illustrated as:

A. Unreduced
B. Reduced
C. Reduced and provisionally stabilized
D. Definitively stabilized
Pitfall: compartment syndrome

Take care not to use excessive force during the casting procedure. Avoid putting too much pressure
on the cast while holding the reduction.
It is also important to avoid flexion of the hip and knee beyond 90° as extremes of flexion are
associated with an increased risk of compartment syndrome.
2. Material and equipment

Material
Tubular bandage (stockinette) sized both for leg and for body
Cast padding
Felt
Casting material: fiberglass or plaster of Paris
Equipment
Hip spica box or table
Folded towel as abdominal spacer
3. Patient preparation
Read the additional material on preoperative preparation .

Dressing

Cut a generous length of tubular bandage to dress the injured leg and a larger
diameter tube for the torso. Tape the two parts of the tubular bandage together to
prevent separation of the bandages as the child is moved.

Place the back support for the spica box against the patient's skin underneath the
tubular bandage.
Placement on hip spica box

Transfer the anesthetized child onto the hip spica box. Make sure that enough
people are available to help positioning and stability.

The child’s sacrum should rest on the back support with its perineum against the
padded post. The shoulders should be supported by the spica box leaving almost
the entire torso free for casting.

The back support can be secured to the apparatus with tape.

Pitfall: Avoid inadvertent extubation during transfer and casting. Discuss airway management with
the anesthetist beforehand.
4. Leg position and closed reduction
In general, unstable pediatric femoral fractures are reduced with gentle traction
with the leg placed in 45–60° of hip flexion, 30–45° of hip abduction and a few
degrees of external rotation. This helps align the distal fragment to the proximal
femur, which is typically flexed, abducted and externally rotated due to muscle
forces.

For more proximal fractures, more hip flexion may be indicated.

For convenience and child positioning the knee is flexed to about 70°. This allows
for comfort whilst lying and sitting.
Confirmation of reduction

Check the reduction under image intensification, this is particularly important for
unstable fractures.

Up to 100% displacement and 2 cm of shortening are acceptable and will not result
in any long-term malalignment.

Coronal and sagittal angulation of up to 10–30° may also be acceptable. This is

dependent on the age of the child and modeling capacity.

5. Single-leg spica

Dressing

Place a folded towel over the central abdomen, inside the tubular bandage, to create
space in the cast for breathing. Bring the tail of the towel towards the neck for ease
of removal.
Padding

Apply a layer of cast padding, using a larger width for the body and a narrower one
for the leg.

The cast extends from the nipple line, or just below, to just above the malleolus of
the ipsilateral ankle.

Consider adding thick felt over the padding at the free edges of the chest and leg.
Cast application

Apply a first layer of cast material to the leg and body sections, taking care to
connect leg to body securely, in a figure of eight (spica technique).

Pitfall: While not common, compartment syndrome may occur after application of a spica cast. The
cast should therefore end above the ankle to allow evaluation of pulses and foot and ankle
movement.
Reinforcing slabs of casting material may be applied between the body and leg
segments.

Molding to maintain reduction

Mold the thigh segment of the cast to maintain reduction of the fracture. The
anterolateral border of the cast should be molded to be flat, or mildly concave, at
the fracture site. Some surgeons mold enough to produce 10° of initial valgus. This
helps prevent the common fracture displacement into varus and apex anterior
angulation. The pull of the hip abductors and the hip flexors on the proximal
fragment are the deforming forces producing this displacement.

Pressure should be continued until the cast hardens. However, the cast will not
achieve full strength for 36 hours.

Finalizing the cast

Fold the tubular bandage and padding over the edges before applying the final layer
of casting material.
Once the cast material is hardened transfer the child from the spica box and remove
the abdominal towel and the back support from the cast.

Trim the edges of the cast, to allow flexion of the opposite hip and adequate access
to the perineal area.

Consider adding waterproof adhesive tape to the perineal edge of the cast.
Splitting the cast

If the cast around the abdomen has been applied too tightly, split it down the side
and spread to allow for expansion or remove and reapply it.

6. One-and-a-half- and two-leg spica

One-and-a-half- and two-leg spicas are applied in the same way as the single-leg
spica with the cast, on the contralateral leg, extended to the knee or ankle.

Apply reinforcing slabs of casting material across the hip region of both legs.

Option: bar

Consider the addition of a bar between the two legs to provide more stability to the
cast.
7. Removal of spica cast
The spica cast can be removed once healing is demonstrated on x-ray. This is age
dependent and should generally be possible within 4–6 weeks.

8. Aftercare

Mobilization

Mobilization with crutches or a walker commences after completion of

nonoperative treatment of the fracture.

Physical therapy may be required for gait training, hip and knee range-of-motion
exercises and muscle strengthening.

Activities involving running, and jumping are not recommended for three months.
Follow-up

Clinical and radiological follow-up is usually undertaken after 2–4 weeks.

Clinical assessment of leg length and alignment is recommended at one-year. It

uses a tape measure from the ASIS to the medial malleolus.
If there is any concern about leg length discrepancy or malalignment, long-leg x-
rays are recommended.

Leg length is measured from the femoral head to the ankle joint.
Traction with delayed spica casting
1. General considerations

Introduction

Treatment with traction requires skillful application of the device and careful
attention to detail with constant monitoring throughout the treatment period to
avoid skin problems or vascular compromise.

Once the child is comfortable and moving or callus formation is visible on x-ray
remove the traction and convert into a spica cast.

Traction types

There are a variety of devices that depend on the patient’s age, weight, fracture
configuration, and resources available.

In children up to 2 years of age with a bodyweight up to 12–15 kg, overhead skin

traction is preferable.

In children older than 2 years and heavier than 12–15 kg, longitudinal traction is an
alternative. Traction can be applied with an adhesive bandage to the skin.
Disadvantages include malunion and prolonged hospital stay.
An alternative in children older than 2 years is 90/90 traction. Less weight is
needed because of the support under the upper legs and fewer skin problems are
therefore seen. A further advantage of this method is rotational control, which can
be useful in unstable fracture patterns.

Preparation
Read the additional material on preoperative preparation .

2. Overhead skin traction

Position the patient supine on a bed.

Start with the uninjured side as this causes less pain.

Position the stirrup of the traction set with the strings for weight attachment at the
foot leaving space for ankle movement.

Apply the long adhesive bandages from ankle to hip to distribute the skin tension
forces over a large area to prevent blisters and skin necrosis.

Wrap a bandage over the adhesive bandage to further reduce shear forces.
Use an assistant to apply gentle traction and provide stability when applying the
bandage on the injured side.

Position the hip in 90° flexion and use sufficient weight to raise the buttocks just
above the sheet, producing the correct amount of traction on the leg.
Perform regular neurovascular observations and check for loosening of the
bandage.

3. Longitudinal skin traction

Place the patient supine on the bed.

Position the stirrup of the traction set with the strings for weight attachment at the
foot leaving space for ankle movement. Use an assistant to apply slight traction and
provide stability when applying the bandage.

Apply the long adhesive bandages from ankle to hip to distribute the skin tension
forces over a large area to prevent blisters and skin necrosis. Wrap a bandage over
the adhesive bandage to further reduce shear forces.

Apply the sling just above the knee and place the leg on a support, eg a pile of
towels, to produce 30° knee flexion.

This neutralizes the muscle forces, controls rotational deformities, and maintains
the femoral bow, which may require a small pillow or towel under the thigh.

The resulting traction direction should be in line with the femoral axis.

The traction weight is determined by the age and weight of the child and should be
sufficient to maintain length and alignment. 500 g per year of age is a good initial
weight to use. The foot of the bed should be raised, tilting the bed, to stop the child
being pulled down the bed.
Perform regular neurovascular observations and check for loosening of the
bandage.

4. 90/90 traction
Place the patient supine with both lower legs on a support and the hip and knee
flexed to 90°.

Apply an adhesive bandage to the entire upper leg on the injured side.

Adjust the lower leg support so that the buttocks are just lifted from the bed and
stabilize the lower leg with a second adhesive bandage.
5. Delayed spica casting
Once the child is comfortable and moving or callus formation is visible on x-ray
remove the traction and convert into a spica cast .

6. Removal of spica cast

The spica cast can be removed once healing is demonstrated on x-ray. This is age
dependent and should generally be possible within 4–6 weeks.

7. Aftercare

Mobilization

Mobilization with crutches or a walker commences after completion of

nonoperative treatment of the fracture.

Physical therapy may be required for gait training, hip and knee range-of-motion
exercises and muscle strengthening.

Activities involving running, and jumping are not recommended for three months.

Follow-up

Clinical and radiological follow-up is usually undertaken after 2–4 weeks.

Clinical assessment of leg length and alignment is recommended at one-year. It

uses a tape measure from the ASIS to the medial malleolus.
If there is any concern about leg length discrepancy or malalignment, long-leg x-
rays are recommended.

Leg length is measured from the femoral head to the ankle joint.
ESIN (retrograde)
1. General considerations
The ESIN method involves closed reduction and internal fixation with elastic nails.

It is difficult to treat shaft fractures of the middle and proximal third with antegrade
nail insertion as the nail entry sites are close to the fracture and the configuration of
the nails does not produce sufficient stability.

Using a retrograde nail construct will provide sufficient stability in these fractures.
2. Instruments and implants

Instrument set for ESIN

2.5–4.0 mm elastic nails
Awl or drill
Inserter
Hammer
End caps and insertion device
Impactor
Extraction plier
Nail cutter
The end cutter is useful to avoid sharp ends and soft-tissue irritation.
The F-tool can be helpful to align the femur.
Nail diameter

For optimal stability, the nail diameter should be between 33% and 40% of the
narrowest part (isthmus) of the medullary canal.

Both nails need to be of the same diameter.

Pearl: To estimate the optimal nail diameter place the selected nail on the leg parallel to the bone and
check with an image intensifier (as shown in the illustration).
 For later precontouring mark the level of the fracture site on the nail.

3. Patient preparation and approach

Patient positioning

Place the patient in a supine position on a radiolucent fracture table with or without
traction.

When positioning the patient check the rotational alignment of the uninjured femur.
Approach

Expose the bone at both entry points .

4. Opening the canal

Place the awl or drill directly onto the bone and perforate the near cortex, under
direct vision, perpendicular to the bone.

Do not hammer the awl to avoid perforation of the far cortex.

When the medullary canal is entered, lower the awl or drill 45° to the shaft axis.
Advance it with oscillating movements to produce an oblique canal.

5. Nail insertion
Precontour both nails with the apex at the level of the fracture site.
The nail bend should be about three times the diameter of the medullary canal.

Insert the first nail through the lateral entry point into the intramedullary canal and
advance it towards the fracture site with an oscillating maneuver.
Pearl: Insert the nail with the tip perpendicular to the shaft axis until the far cortex is felt. Rotate the
nail 180° and advance it using the curved side of the tip.
If the tip is stuck in the far cortex and cannot be advanced, remove the nail and bend the tip to give a
slightly more pronounced curvature.

Pearl: A short working length (3–5 cm) between the entry point and the inserter improves control of
the nail during insertion.
Insert the second nail into the medial entry point in an identical manner.

Pearl: Use a T-handle on the medial nail to act as a joystick reduction tool. This also avoids changing
the inserter from one nail to the other.
Pitfall: Make sure that the second nail has not crossed the first more than once to avoid the
corkscrew phenomenon.
If this happens reinsert a new nail.
6. Proximal fragment advancement
Reduce the fracture freehand, with a reduction tool or with a fracture table.

Advance both nail tips with an oscillating maneuver past the fracture site into the
proximal fragment.

Use the nails as joysticks to reduce the main fragments.

If necessary, use an F-tool to align both fragments.
If this is unsuccessful use a bone hook or Steinmann pin through a small incision.
Open reduction (through a limited lateral approach ) may be necessary if closed
reduction cannot be achieved.
Assessment of rotational alignment

Confirm rotational alignment of the femur clinically and radiographically before

fixing the second fragment. This can be done by:
Fluoroscopy of the fracture site (matching shaft diameters)
Comparing internal and external rotation to the contralateral side (consider preparing and draping the
uninjured side as well)
Fluoroscopy of proximal femur (lesser trochanter profile)

For more detail see the additional material on assessment of rotation .

7. Final seating
Advance the nail started on the medial side and impact it at least to the level of the
lesser trochanter.

Impact the nail started on the lateral side towards the greater trochanter. Optimally
the nail tips are at the same level.

Align the nail tips so that they diverge.

For a fracture in the proximal third advance the medial nail into the femoral neck
and the lateral nail into the greater trochanter.

Pitfall: penetration of femoral neck

Take care not to advance the medially introduced nail too far and thereby penetrate the femoral neck.
Use lateral image intensifier views to confirm correct position.
8. Cutting the nails
Cut the nails with the dedicated nail cutter.
If this is not available, withdraw the nails far enough to apply the nail cutter.

Reinsert the nails so at least 1 cm of the nail remains outside the bone.
Pearl: Bend the nail to just elevate it from the bone as this facilitates removal. Further bending is not
recommended as it may cause skin irritation.
End caps

End caps are not recommended in transverse fractures as they may prevent fracture
compression with weight bearing.
9. Final assessment
Check the range of internal and external rotation of the leg and compare with the
contralateral limb.

Obtain final AP and lateral fluoroscopic views.

10. Aftercare

Immediate postoperative care

The patient should get out of bed and begin ambulation with crutches on the first
postoperative day.

In most cases the postoperative protocol will be protected weight bearing for the
first 4 weeks.
Analgesia

Routine pain medication is prescribed for 3–5 days postoperatively.

Neurovascular examination

The patient should be examined frequently, to exclude distal neurovascular

compromise.

Compartment syndrome, although rare, should be considered in the presence of

severe swelling, increasing pain, and changes to neurovascular signs.

Discharge care

Discharge from hospital follows local practice and is usually possible after 1–3
days.

Mobilization

The patient should ambulate with crutches and begin knee range-of-motion
exercises.

Follow-up

Clinical and radiological follow-up is usually undertaken every 2–8 weeks until
radiographic healing and restoration of function.
Clinical assessment of leg length and alignment is recommended at one-year.

Clinical assessment of leg length uses a tape measure from the ASIS to the medial
malleolus.

If there is any concern about leg length discrepancy or malalignment, long-leg x-

rays are recommended.

Leg length is measured from the femoral head to the ankle joint.
Implant removal

If the patient develops symptoms related to the implant, it can be removed once the
fracture is completely healed, usually 6–12 months following injury.
Traction
1. General considerations

Introduction

Treatment with traction requires skillful application of the device and careful
attention to detail with constant monitoring throughout the treatment period to
avoid skin problems or vascular compromise.

All types of traction can be converted to a spica cast or definitive surgical

stabilization.

Traction types

There are a variety of devices that depend on the patient’s age, weight, fracture
configuration, and resources available.

In children up to 2 years of age with a bodyweight up to 12–15 kg, overhead skin

traction is preferable.
In children older than 2 years and heavier than 12–15 kg, longitudinal traction is an
alternative. Traction can be applied with an adhesive bandage to the skin or with
skeletal fixation using a transosseous pin. Disadvantages include malunion,
prolonged hospital stay and pin-track infections if skeletal devices are used.
An alternative in children older than 2 years is 90/90 traction. Less weight is
needed because of the support under the upper legs and fewer skin problems are
therefore seen. A further advantage of this method is rotational control, which can
be useful in unstable fracture patterns.

Complications of skeletal traction

Management of femoral fractures with skeletal traction in older children has

become less common because of frequent significant complications, which include:
Growth plate injury
Pin-track infection
Muscle wasting
Pressure sores
Increased resource utilization
Inadequate reduction
Growth plate injury

Carefully place the traction pin under image intensifier control to avoid this
complication.

If an image intensifier is not available, place the pin proximal to the normal level of
the superior pole of the patella to avoid the growth plate.
Pin-track infection

The following steps are necessary to manage pin loosening or pin-track infection:
Remove the traction pin and place a new pin in a healthy location, proximal to the area of involved
skin.
Debride the pin site in the operating theater, using curettage and irrigation.
Take specimens for microbiological study to guide appropriate antibiotic treatment if necessary.

Muscle wasting

A patient in traction must regularly perform exercises of all muscle groups, in bed
under the supervision of a physiotherapist.
Pressure areas

Good nursing care is required to prevent soft-tissue breakdown over pressure areas.
This involves frequent skin checks and regular offloading areas at risk.
Increased resource utilization

Traction for 6 weeks is an expensive use of hospital resources and should only be
considered when other option are unavailable.
Inadequate reduction

Whilst length is often preserved, it is difficult to maintain alignment and rotation

with traction. This may result in fracture malunion that requires surgical correction.

Preparation

Read the additional material on preoperative preparation .

2. Overhead skin traction

Position the patient supine on a bed.

Start with the uninjured side as this causes less pain.

Position the stirrup of the traction set with the strings for weight attachment at the
foot leaving space for ankle movement.

Apply the long adhesive bandages from ankle to hip to distribute the skin tension
forces over a large area to prevent blisters and skin necrosis.

Wrap a bandage over the adhesive bandage to further reduce shear forces.
Use an assistant to apply gentle traction and provide stability when applying the
bandage on the injured side.

Position the hip in 90° flexion and use sufficient weight to raise the buttocks just
above the sheet, producing the correct amount of traction on the leg.
Perform regular neurovascular observations and check for loosening of the
bandage.

3. Longitudinal skin traction

Place the patient supine on the bed.

Position the stirrup of the traction set with the strings for weight attachment at the
foot leaving space for ankle movement. Use an assistant to apply slight traction and
provide stability when applying the bandage.

Apply the long adhesive bandages from ankle to hip to distribute the skin tension
forces over a large area to prevent blisters and skin necrosis. Wrap a bandage over
the adhesive bandage to further reduce shear forces.

Apply the sling just above the knee and place the leg on a support, eg a pile of
towels, to produce 30° knee flexion.

This neutralizes the muscle forces, controls rotational deformities, and maintains
the femoral bow, which may require a small pillow or towel under the thigh.

The resulting traction direction should be in line with the femoral axis.

The traction weight is determined by the age and weight of the child and should be
sufficient to maintain length and alignment. 500 g per year of age is a good initial
weight to use. The foot of the bed should be raised, tilting the bed, to stop the child
being pulled down the bed.
Perform regular neurovascular observations and check for loosening of the
bandage.

4. 90/90 traction
Place the patient supine with both lower legs on a support and the hip and knee
flexed to 90°.

Apply an adhesive bandage to the entire upper leg on the injured side.

Adjust the lower leg support so that the buttocks are just lifted from the bed and
stabilize the lower leg with a second adhesive bandage.
5. Skeletal traction

Skeletal traction via tibial or femoral pin

Skeletal traction may be used as an alternative, particularly if it is decided to use

traction as the definitive treatment of an older child.

Note: Consider definitive fixation if subjecting a child to an anesthetic for pin placement.
The pin may be inserted either in the distal femur or the proximal tibia. Take care
not to injure the growth plate.

In a child, this is generally performed under general anesthetic.

Preparation
Pack with:
Sterile towels
Disinfectant
Syringe
Needles
Scalpel with pointed blade
Sharp pointed threaded pin
Jacobs chuck with T-handle
Stirrup
Power driver

Pin insertion

At the entry point, perform a stab incision through the skin with a pointed blade.

A threaded pin is preferred as it has a lower tendency to back out.

Insert the pin into the metaphysis about 2 cm away from the growth plate.

Use of a power driver is recommended.

As the pin is felt to penetrate the far cortex, advance carefully until its point is
palpable, and make a small stab incision in the overlying skin.

Ensure that there is no skin tension at the entry and exit points. Perform a small
relieving incision if necessary.
Mount the stirrup to the pin.

Make sure that the stirrup is freely mobile around the traction pin, to prevent
rotation of the pin within the bone. Rotating pins loosen quickly and this
significantly increases the risk of pin-track infection.
Pin-site care

There is no universally agreed protocol for pin-site care but the following points
are recommended. They should be undertaken until removal of the traction.
The pin-insertion sites should be kept clean. Any crusts or exudates should be removed. The pins may
be cleaned with saline and/or disinfectant solution/alcohol. The frequency of cleaning depends on the
circumstances and varies from daily to weekly.
Antibiotic solutions and skin preparations are not recommended for routine pin-site care.

6. Control of length and rotation

Check length and rotation daily.

Increase or decrease the traction weight to correct the length if needed.

Checking rotational alignment is reliant on clinical examination. Generally, if the

patella is facing up then the rotational alignment will be satisfactory.

7. Removal of traction
Traction can be removed once healing is demonstrated on x-ray. This is age
dependent and equates to approximately 1 week of traction per year of age.

8. Aftercare

Mobilization

Mobilization with crutches or a walker commences after completion of

nonoperative treatment of the fracture.

Physical therapy may be required for gait training, hip and knee range-of-motion
exercises and muscle strengthening.

Activities involving running, and jumping are not recommended for three months.
Follow-up

Clinical and radiological follow-up is usually undertaken after 2–4 weeks.

Clinical assessment of leg length and alignment is recommended at one-year. It

uses a tape measure from the ASIS to the medial malleolus.
If there is any concern about leg length discrepancy or malalignment, long-leg x-
rays are recommended.

Leg length is measured from the femoral head to the ankle joint.
ESIN (antegrade)
1. General considerations
The ESIN method involves closed reduction and internal fixation with elastic nails.

It is difficult to treat shaft fractures of the distal third with retrograde nail insertion
as the nail entry sites are too close to the fracture and the configuration of the nails
does not produce sufficient stability.

Using an antegrade nail construct will provide sufficient stability in these fractures.
2. Instruments and implants

Instrument set for ESIN

2.5–4.0 mm elastic nails
Awl or drill
Inserter
Hammer
End caps and insertion device
Impactor
Extraction plier
Nail cutter
The end cutter is useful to avoid sharp ends and soft-tissue irritation.
Nail diameter

For optimal stability, the nail diameter should be between 33% and 40% of the
narrowest part (isthmus) of the medullary canal.

Both nails need to be of the same diameter.

Pearl: To estimate the optimal nail diameter place the selected nail on the leg parallel to the bone and
check with an image intensifier (as shown in the illustration).
 For later precontouring mark the level of the fracture site on the nail.

3. Patient preparation and approach

Patient positioning

Place the patient in a supine position on a traction table or radiolucent fracture

table.

The radiolucent fracture table has the advantage that the leg can be freely
manipulated during the procedure. Muscle forces can be neutralized by flexing the
knee with a support underneath.

When positioning the patient check the rotational alignment of the uninjured femur.

Approach

Expose the bone at the entry points .

4. Opening the canal

Position of entry points

The usual entry points are 0.5–1 cm distal to the greater trochanteric growth plate.

Entry points should be at least 2 cm apart in the axial plane and at least 1 cm apart
in the lateral plane. If they are too close, the cortex may split during the insertion of
the nails.

There is a lower risk of iatrogenic fracture if both entry points are made in the
metaphyseal bone proximal to the lesser trochanter. Alternatives include entry
points in the lateral aspect of the greater trochanter.

Proximal entry point

Place the awl or drill directly onto the bone and perforate the near cortex, under
direct vision, perpendicular to the bone.

Do not hammer the awl to avoid perforation of the far cortex.

When the medullary canal is entered, lower the awl or drill 45° to the shaft axis.
Advance it with oscillating movements to produce an oblique canal.
Second entry point

Enter the medullary canal at the distal entry point with an identical technique.
5. Nail insertion
Decide whether the crossing point of the nails is to be proximal or distal to the
fracture site.

Crossing the nails at the level of the fracture must be avoided.

Precontour both nails in the distal third with the apex at the predetermined level.

The maximum nail bend should be at the level of the fracture about three times the
diameter of the medullary canal.
Insert the nail through the proximal entry point into the intramedullary canal and
advance it towards the fracture site with an oscillating maneuver.
Pearl: Insert the nail with the tip perpendicular to the shaft axis until the far cortex is felt. Rotate the
nail 180° and advance it using the curved side of the tip.
If the tip is stuck in the far cortex and cannot be advanced, remove the nail and bend the tip to give a
slightly more pronounced curvature.

Pearl: A short working length (3–5 cm) between the entry point and the inserter improves control of
the nail during insertion.
Insert the second nail into the distal entry point and advance it towards the fracture
site.
Once it has good contact with the opposite cortex, with the tip having advanced
about two-thirds distally in the medullary canal, the contour of the nail is changed
to an S-shape with the following maneuver:
1. Rotate the nail 180°.
2. Bend the proximal portion of the nail, which is outside the bone, in the opposite direction to the
previous bend.
3. Apply a constant bending force whilst inserting the nail.

This produces an S-shape, which will provide contact with the lateral cortex at the
fracture site and with the medial cortex of the proximal third of the femoral shaft.
Pitfall: Make sure that the second nail has not crossed the first more than once to avoid the
corkscrew phenomenon.
If this happens reinsert a new nail.
6. Distal fragment advancement
Reduce the fracture freehand, with a reduction tool or with a traction table.

Advance both nail tips, with an oscillating maneuver, past the fracture site into the
distal fragment.
If it is difficult to advance either nail while it is positioned against the cortex, rotate
the tip towards the center of the bone and advance it across the fracture.
Once the nail has crossed the fracture, rotate the nail tip to return to the initial
position.
If this is unsuccessful use a bone hook or Steinmann pin through a small incision.
Open reduction (through a limited lateral approach ) may be necessary if closed
reduction cannot be achieved.
Assessment of rotational alignment

Confirm rotational alignment of the femur clinically and radiographically. This can
be done by:
Fluoroscopy of the fracture site (matching shaft diameters)
Comparing internal and external rotation to the contralateral side (consider preparing and draping the
uninjured side)
Fluoroscopy of proximal femur (lesser trochanter profile)

For more detail see the additional material on assessment of rotation .

7. Final seating
Advance the nails and impact them medially and laterally into their respective
condylar regions.

Align the nail tips so that they diverge.

If more stability is necessary and/or the fracture is very distal, the physis can be
perforated with the nails.
A single pass of a smooth nail across a growth plate is unlikely to produce a growth
arrest.

In very distal fractures it is impossible to get the maximum bend of the nails at the
level of the fracture. In this situation the nails should be contoured to cross well
above the fracture to maximise diversion at the fracture.

8. Cutting the nails

Cut the nails with the dedicated nail cutter.
If this is not available, withdraw the nails far enough to apply the nail cutter.

Reinsert the nails so at least 1 cm of the nail remains outside the bone.
 Pearl: Bend the nail to just elevate it from the bone as this facilitates removal. Further bending is not
recommended as it may cause skin irritation.

End caps

End caps are not recommended in transverse fractures as they may prevent fracture
compression with weight bearing.
9. Final assessment
Check the range of internal and external rotation of the leg and compare with the
contralateral limb.

Obtain final AP and lateral fluoroscopic views.

10. Aftercare

Immediate postoperative care

The patient should get out of bed and begin ambulation with crutches on the first
postoperative day.

In most cases the postoperative protocol will be protected weight bearing for the
first 4 weeks.
Analgesia

Routine pain medication is prescribed for 3–5 days postoperatively.

Neurovascular examination

The patient should be examined frequently, to exclude distal neurovascular

compromise.

Compartment syndrome, although rare, should be considered in the presence of

severe swelling, increasing pain, and changes to neurovascular signs.

Discharge care

Discharge from hospital follows local practice and is usually possible after 1–3
days.

Mobilization

The patient should ambulate with crutches and begin knee range-of-motion
exercises.

Follow-up

The patient is usually reviewed 2 weeks after surgery for clinical and radiographic
assessment, and wound check.
Clinical assessment of leg length and alignment is recommended at one-year.

Clinical assessment of leg length uses a tape measure from the ASIS to the medial
malleolus.

If there is any concern about leg-length discrepancy or malalignment, long-leg x-

rays are recommended.

Leg length is measured from the femoral head to the ankle joint.
Implant removal

If the patient develops symptoms related to the implant, it can be removed once the
fracture is completely healed, usually 6–12 months following injury.
MIPO
1. General considerations

Minimally invasive osteosynthesis

Bridge plates inserted through a minimally invasive (MIO) approach leave the soft
tissues intact over the fracture site. The incisions are made proximally and distally,
and the plate is inserted through a submuscular tunnel. This normally requires
monitoring under image intensification.

Bridge plating

This technique uses the plate as an extramedullary splint, fixed to the two main
fragments, leaving the intermediate fracture zone untouched. Anatomical reduction
of intermediate fragments is not necessary. Furthermore, direct manipulation would
risk disturbing their blood supply. If the soft-tissue attachments to these fragments
are preserved, and the fragments are relatively well aligned, healing is enhanced.

Alignment of the main shaft fragments can be achieved indirectly with the use of
traction and the support of indirect reduction tools, or with the implant.

Mechanical stability, provided by the bridging plate, is adequate for gentle

functional rehabilitation and results in healing with abundant callus formation.

Note on illustrations
Throughout this section generic fracture patterns are illustrated as:
A. Unreduced
B. Reduced
C. Reduced and provisionally stabilized
D. Definitively stabilized

Reduction

It is important to restore axial alignment, length, and rotation.

Reduction can be performed with a fracture table, femoral distractor, external

fixator, or with the implant.

The preferred method depends on the fracture and soft-tissue injury pattern, the
chosen stabilization device, and the experience and skill of the surgeon.
2. Plate selection

Plate type

A small (3.5 mm) or large narrow (4.5 mm) plate is chosen.

A locking plate is a good option for fractures with a short end segment. The plate
does not need to be contoured precisely to fit the bone, as it functions as an internal
fixator. Attaching it to the bone does not alter fracture alignment, as locking screws
do not pull the main bone fragments to the implant. If cortical screws are used
contouring is important.
A radiograph of the contralateral femur can help to decide between a straight or a
curved plate.

A plate with a beveled end may be easier to insert.

Plate length and number of screws

The plates for a bridging technique should be longer than for conventional
“anatomical” fixation, to distribute the forces more widely, as well as to provide
sufficient stability.

A minimum of two and up to four bicortical screws should be inserted into each
fracture fragment.

Relative stability results from leaving plate holes empty over the fracture zone.

Up to half the screw holes need to be filled with screws and no screws are inserted
into the fracture zone.

3. Patient preparation and approach

Patient positioning

Place the patient in a supine position on a traction table or a translucent table with a
bump under the ipsilateral flank.
Approach

For this procedure a MIO approach is used.

4. Preliminary reduction
The use of a traction table can be beneficial in adolescents especially when
operating without an assistant.

For younger children manual traction is often sufficient.

If a traction table is not used, folded linen bolsters under the fracture zone may
facilitate reduction.
 Pearl: Use a sheet around the opposite pelvis and attached to the side of the operating table to
provide countertraction in the supine position.

5. Contouring and insertion of the plate

Contouring the plate

Contouring the plate over the fracture zone is not normally required.

It is necessary to contour the ends of a conventional plate used with cortical screws
to address the shape of the proximal and distal femur.

A locking plate used as an internal fixator does not have to be contoured but slight
contouring may be necessary to avoid soft-tissue irritation.

Direction of plate insertion

Insert the plate from the proximal end, if the fracture is located more proximally, or
from the distal end, if the fracture is located more distally.
Preparation of the plate tunnel

Options for preparation of the plate path along the distal main fragment include:
Insert the tip of the plate and slide it extraperiosteally along the distal main fragment.
Insert a long pair of scissors, spread them, and then pull backwards.
Insert a periosteal elevator and slide it extraperiosteally along the distal main fragment.
Use the MIO instruments.

6. Reduction and fixation

Principle

Further adjustment is often needed after the preliminary reduction to achieve

optimal alignment. In such cases, the final reduction will be achieved using the
implant and further multistep reduction techniques.
Plate fixation to first main fragment

The order of screw insertion depends on the direction of plate insertion. In the
following example, the procedure for a plate inserted through a proximal approach
is shown.

Place the plate on the lateral aspect of the femur and the check the position with
image intensification.
Insertion of the first screw

Insert the first cortical screw into the most proximal plate hole.
Insertion of the second screw

The position of the second screw will determine the lateral alignment of the plate
on the proximal fragment.

Use a K-wire or Schanz screw to push the proximal fragment into position and
achieve the correct alignment between the plate and the bone.

Alternatively, this can be achieved directly through a second incision, using a

periosteal elevator.

Insert the second cortical screw.

Indirect reduction

Manual traction is often sufficient to align the distal femur to the plate.

A bump placed under the fracture site helps with sagittal fracture alignment.

K-wires can be used for provisional fixation of the plate.

Assessment of rotational alignment

Confirm rotational alignment of the femur clinically and radiographically before

fixing the second fragment. This can be done by:
Fluoroscopy of the fracture site (matching shaft diameters)
Comparing internal and external rotation to the contralateral side (consider preparing and draping the
uninjured side as well)
Fluoroscopy of proximal femur (lesser trochanter profile)

For more detail see the additional material on assessment of rotation .

Plate fixation to second main fragment

Insertion of the third screw

Insert the third screw through the most distal plate hole into the second main
fragment.
Insertion of the fourth screw

If the distal fragment requires adjustment to obtain the correct lateral position, the
following reduction techniques may be helpful before inserting of the fourth screw:
Placement of a linen bolster under the distal fragment
Using a periosteal elevator, inserted through a small additional incision to push the fragment into the
correct position
Using a percutaneous K-wire or Schanz screw

Insert the fourth cortical screw.

Final screw insertion

At least two bicortical screws must be inserted into each main fragment.

For older or heavier children at least three screws is recommended for each main
fragment.
7. Alternative: internal fixator - locking plate system

Preliminary fixation

A plate used as an internal fixator has the advantage that optimal reduction can be
achieved even if the plate is not correctly precontoured.

Temporarily attach the plate to the bone using K-wires applied through proximal
and distal positioning holes, or through the most peripheral screw holes using
locking towers with appropriate sleeves.

Insert two conventional screws proximal and distal to the fracture zone.

Reduction

Alignment is achieved by tightening the two conventional screws.

There is a gap between the bone and the implant which is to be anticipated and
ignored.
In cases where reduction is difficult a bone holding clamp can be used via a small
incision.

Final screw fixation

The final reduction is achieved by inserting locking head screws according to the
preoperative plan with optional removal of the conventional reduction screws.

8. Final assessment
Check the range of internal and external rotation of the leg and compare with the
contralateral limb.

Obtain final AP and lateral fluoroscopic views.

9. Aftercare

Immediate postoperative care

The patient should get out of bed and begin ambulation with crutches on the first
postoperative day.

In most cases partial weight bearing is permitted until preliminary callus is present
at 4–6 weeks.
Analgesia

Routine pain medication is prescribed for 3–5 days postoperatively.

Neurovascular examination

The patient should be examined frequently, to exclude distal neurovascular

compromise.

Compartment syndrome, although rare, should be considered in the presence of

severe swelling, increasing pain, and changes to neurovascular signs.

Discharge care

Discharge from hospital follows local practice and is usually possible after 1–3
days.

Mobilization

The patient should ambulate with crutches and begin knee range-of-motion
exercises.

Follow-up

The patient is usually reviewed 2 weeks after surgery for clinical and radiographic
assessment, and wound check.
Clinical assessment of leg length and alignment is recommended at one-year.

Clinical assessment of leg length uses a tape measure from the ASIS to the medial
malleolus.

If there is any concern about leg length discrepancy or malalignment, long-leg x-

rays are recommended.

Leg length is measured from the femoral head to the ankle joint.
Implant removal

If the patient develops symptoms related to the implant, it can be removed once the
fracture is completely healed, usually 6–12 months following injury.
Open reduction; plate fixation
1. General considerations

Introduction

Open plating is less biologically favorable because soft-tissue and especially

periosteal stripping will slow fracture healing. In addition, muscle dissection can
contribute to discomfort and joint stiffness.

Soft-tissue dissection should be minimized during open plating.

Note on illustrations

Throughout this section generic fracture patterns are illustrated as:

A. Unreduced
B. Reduced
C. Reduced and provisionally stabilized
D. Definitively stabilized
Compression vs bridge plating

Transverse and short oblique fractures can be made more stable by compressing
using gliding holes in the plate.

Bridge plating relies on indirect fracture reduction.

Most children’s fractures heal readily and compression is not mandatory.

The approach that involves the least dissection of the fracture site to obtain stable
fixation is preferred.
2. Selection of implants

Plate size

For younger children a small fragment set can be used (3.5 mm). For older children
and adolescents, a large fragment plate, typically a narrow 4.5 mm plate, can be
used.
Plate length

Select a plate long enough to allow three bicortical screws in each main fragment.

If longer plates are used, a curved plate may provide a better fit and accommodate
the sagittal anatomy of the femur.

An x-ray of the contralateral side is useful for templating.

3. Patient preparation and approach

Patient positioning

Place the patient in a supine position on a traction table or a translucent table with a
bump under the ipsilateral flank.
Approach

For this procedure a lateral approach is used.

4. Reduction
After extraperiosteal exposure of the lateral aspect of the femur, perform direct
reduction using manual traction/traction table, and/or bone reduction forceps.

Anatomical fracture reduction can be observed directly.

With purely transverse fractures, it is rarely possible to achieve reduction by
forceful longitudinal traction alone. It is usually necessary to increase the
angulation (apex anteriorly) to reduce the posterior cortices, and then straighten the
bone to reduce the whole fracture.

5. Plate contouring
Plate positioning

Position the plate on the lateral aspect of the femur.

Fitting the plate to the bone

Depending on the planned location, proximal and distal contouring of the plate may
be necessary.

Contouring is aided by a stable provisional reduction and a malleable template that

can be shaped along the bone surface.

The malleable template is then used as a guide for shaping the plate to the bone.

Pearl: Undercontour a plate to be used in compression, to avoid gapping of the far cortex.
6. Fixation

Application of the plate

Avoid periosteal stripping when exposing the bone for plate fixation.

Position the plate over the fracture so that at least three holes are available in the
proximal and distal fragments.
Screw insertion

Insert the first screw close to the fracture site.

Confirm plate position relative to the fragment before placing the second screw.

Insert the second screw through the plate in the same fragment and tighten both
screws.
If unstable, fix the plate to one fragment and then reduce the other fragment onto
the plate, using a bone holding forceps.

Assessment of rotational alignment

Confirm rotational alignment of the femur clinically and radiographically before
fixing the second fragment. This can be done by:
Direct visualization of fracture site
Fluoroscopy of fracture site
Comparing internal and external rotation to the contralateral side
Fluoroscopy of proximal femur (lesser trochanter profile)

For more detail see the additional material on assessment of rotation .

Insertion of screws in other main fragment

Insert the third and fourth screws in the other main fragment.
Option: compression plating

For transverse or short oblique fractures, the third and fourth screw can be inserted
in compression mode.

Place the screw eccentrically in the gliding hole away from the fracture.

For an oblique fracture create an axilla and insert the compressing screw on the
acute angled side of the fracture.
Finalizing plate fixation

Insert the remaining screws so there are three bicortical screws in each fragment.

7. Final assessment
Check the range of internal and external rotation of the leg and compare with the
contralateral limb.

Obtain final AP and lateral fluoroscopic views.

8. Aftercare

Immediate postoperative care

The patient should get out of bed and begin ambulation with crutches on the first
postoperative day.

In most cases partial weight bearing is permitted until preliminary callus is present
at 4–6 weeks.
Analgesia

Routine pain medication is prescribed for 3–5 days postoperatively.

Neurovascular examination

The patient should be examined frequently, to exclude distal neurovascular

compromise.

Compartment syndrome, although rare, should be considered in the presence of

severe swelling, increasing pain, and changes to neurovascular signs.

Discharge care

Discharge from hospital follows local practice and is usually possible after 1–3
days.

Mobilization

The patient should ambulate with crutches and begin knee range-of-motion
exercises.

Follow-up

The patient is usually reviewed 2 weeks after surgery for clinical and radiographic
assessment, and wound check.
Clinical assessment of leg length and alignment is recommended at one-year.

Clinical assessment of leg length uses a tape measure from the ASIS to the medial
malleolus.

If there is any concern about leg length discrepancy or malalignment, long-leg x-

rays are recommended.

Leg length is measured from the femoral head to the ankle joint.
Implant removal

If the patient develops symptoms related to the implant, it can be removed once the
fracture is completely healed, usually 6–12 months following injury.
External fixation
1. General considerations

Modular external fixator

The versatility of a modular external fixator is an advantage in the management of

children’s fractures and can accommodate age-specific variations in fracture
biology and anatomy.

An external fixator may be used for definitive management of femoral fractures in

younger children due to the short healing time.

Practical considerations are illustrated in detail in the basic technique for

application of modular external fixator in children.

Specific considerations for the femoral shaft are given below.

Note on illustrations

Throughout this section generic fracture patterns are illustrated as:

A. Unreduced
B. Reduced
C. Reduced and provisionally stabilized
D. Definitively stabilized
Other types of external fixator

Alternative configurations are available and include monolateral or ring systems.

Disadvantages of these systems in children include:

Need for extensive inventory
Excessively stiff construct
Pin size in femoral fractures

External fixation is suitable for all ages, but the pin diameter must be appropriate to
the size of the bone.

Pins with a thread diameter of 3.0–6.0 mm are suitable for femoral fractures and
should typically be between 1/4 and 1/3 of the external bone diameter.

2. Patient preparation and approach

Patient positioning

Place the patient in a supine position without traction on a radiolucent fracture

table, with a bump under the ipsilateral flank.

When positioning the patient check the rotational alignment of the uninjured femur.
Approaches for safe pin placement

For safe pin placement make use of the safe zones and be familiar with the
anatomy of the femur.

3. Frame construction
Pin insertion

Insert the pins via a lateral incision with blunt dissection to the bone.

The exact sequence of pin placement is determined by fracture morphology and

surgeon’s preference.

Make an adequate skin incision over the site of pin insertion.

Use an artery clip for blunt dissection down to the bone.

Distal frame assembly

The most distal pin should be 20 mm proximal to the distal femoral growth plate.

The second pin in the distal fragment can be inserted 15–20 mm distal to the
fracture site.
Attach the appropriately sized rod to the distal pins and tighten the rod-to-pin
clamps.

Proximal frame assembly

Insert pins in a similar fashion, typically just distal to the lesser trochanter and 15–
20 mm proximal to the fracture.

Attach the appropriately sized rod to the pins and tighten the rod-to-pin clamps.

Proximal frame in very proximal fracture

For fixation of fractures in the proximal third of the femoral shaft insert the
proximal pins in the proximal femoral metaphysis.

Avoid crossing the proximal femoral growth plate.

Crossing the trochanteric apophysis is usually well tolerated, particularly in older

children.
Connection of the two partial frames

Loosely apply a connecting rod to the two partial frames.

Reduction and fixation

Under image intensification manipulate the partial frames to achieve correct
reduction.

Do not accept varus angulation.

Tighten the rod-to-rod clamps.

Assessment of rotational alignment

Confirm rotational alignment of the femur clinically by comparing internal and

external rotation to the contralateral side.

In addition to clinical examination, an intraoperative radiological assessment of

rotational alignment may be useful.

For more detail see the additional material on assessment of rotation .

In this example, the knee is placed in the true AP position and the appearance of the
lesser trochanter is compared with the uninjured limb.
Reinforcing the frame

A second bar may be used to span the construct for additional stability. This may be
placed from bar to bar or onto a pin depending on available space.

Pin sites
Check the skin at the pin sites and incise if tethered.

Fully flex the hip and knee to release tethering of vastus lateralis by the pins.

Ensure that there is sufficient space between skin and fixator to accommodate
postoperative swelling.

Dress the pin sites to prevent skin motion.

4. Aftercare

Pin-site care
Pin-care protocol

There is no universally agreed protocol for pin-site care.

The following points are however recommended:

Pin-site care should continue until removal of the external fixator.
The pin sites should be kept clean.
Crusts or exudates should be removed.
The pins may be cleaned with water, saline, disinfectant solution or alcohol. The frequency of
cleaning varies from daily to weekly.
Ointments or antibiotic solutions are not recommended for routine pin-site care.
Pin sites do not need to be protected whilst showering or bathing with clean water, but should be dried
immediately.

Pin-site infection

Initial management is with oral anti-staphylococcal antibiotics.

In case of pin loosening or unresponsive pin site infection, the following steps
should be taken:
Remove all involved pins and place new pins in a healthy location.
Debride the pin sites in the operating theater, using curettage and irrigation.
Take specimens for microbiological culture to guide appropriate antibiotic treatment.

Internal fixation following an infected external fixator pin has a high risk of
infection and should be avoided unless no reasonable alternative is available.

Mobilization

The patient should be encouraged to move the hip and knee, within the limits of
comfort.

In most cases the fixator is not stable enough to allow initial weight bearing. Partial
weight bearing can be resumed when callus is visible, typically at 4 weeks.

Follow-up

The patient should be seen 7–10 days after surgery for a wound check.

X-rays are taken to check stability and alignment.

Fixator removal

Fixator removal is determined by the age of the child and healing rate.

Look for mature callus bridging 3 or 4 cortices of the femur before removing the
frame.

Refractures are a common complication and many surgeons recommend partial

weight bearing with crutches after fixator removal to allow further strengthening of
the callus.
Follow-up for leg-length assessment

Clinical assessment of leg length and alignment is recommended at one-year.

Clinical assessment of leg length uses a tape measure from the ASIS to the medial
malleolus.
If there is any concern about leg length discrepancy or malalignment, long-leg x-
rays are recommended.

Leg length is measured from the femoral head to the ankle joint.
Locked intramedullary nailing (ALFN)
1. General considerations

Introduction

These nails are designed to enter through the lateral aspect of the greater trochanter
and not through the piriformis fossa or trochanteric tip. The lateral entry approach
decreases the chance of damage to the blood supply of the femoral epiphysis (see
neurovascular anatomy ).
Note on illustrations

Throughout this section generic fracture patterns are illustrated as:

A. Unreduced
B. Reduced
C. Reduced and provisionally stabilized
D. Definitively stabilized
2. Instruments and implants

Equipment
Pediatric nailing set
Reamer set

For advice on specific nail types consult the relevant surgical technique guide.

Determination of nail diameter

Young adolescents may have very thick cortex and narrow medullary canal. It is
therefore important to carefully select the nail diameter.

Use pre- or intraoperative x-rays to determine the narrowest point of the medullary
canal from the AP and lateral views and therefore the nail diameter.

Alternatively, select the appropriate diameter after sequential reaming of the canal.
Determination of nail length

Estimate the correct nail length from the preoperative x-ray. An x-ray of the
contralateral side may be needed.

3. Patient preparation and approaches

Patient positioning
Place the patient either in a lateral decubitus or supine position on a traction table
or radiolucent fracture table.

Approaches

The nail entry point lies on the lateral surface of the greater trochanter.

For open reduction a limited lateral approach may be necessary to access the
fracture zone.
4. Insertion of guide pin
On the AP view the entry point is on the lateral aspect of the trochanter, one-third
to one-half way down.

Insert the guide pin into the proximal femur at an angle to the femoral shaft.

This guide pin should stop 2 cm distal to the lesser trochanter and in the center of
the medullary canal on the lateral view.
Overreaming of the proximal femur is a crucial step to facilitate insertion of the
nail.

Open the femur with the opening reamer through the drill sleeve, which will
provide a stop to the drill.

Ream the proximal 75 mm of the proximal femur up to 13 mm to allow the

contoured nail to be inserted.

Remove the guide pin and insert an olive-tipped reaming wire to the level of the
fracture zone.
5. Reduction
Reduce the fracture in a closed fashion with manipulation, traction, and direct
pressure applied with a mallet or similar instrument.

Successful reduction permits passing of the olive-tipped reaming wire.

If this is unsuccessful use a bone hook or Schanz screw through a small incision.
Open reduction (through a limited lateral approach ) may be necessary if closed
reduction cannot be achieved.
6. Opening and reaming the medullary canal
Advance the reaming wire across the fracture zone as far as the distal metaphysis,
with the tip proximal to the growth plate.
Confirm the central position of the reaming wire on both AP and lateral views.
Ream the medullary canal 1–2 mm wider than the selected nail diameter to within
1 cm of the distal physis.

The guide wire is removed, immediately before insertion of the nail.

7. Nail insertion

Assembling nail and insertion handle

Mount the insertion handle onto the nail.

Take care that the nail is of correct length, diameter and side. (Right and left sided
nails are distinct due to the nail geometry.)
Nail insertion

Start inserting the nail manually with light taps, with the handle in an anterior
position.

The handle will rotate into a more lateral position as the nail is advanced into the
shaft due to the inner curve of the femoral canal.
Confirm correct reduction under image intensification.

The nail should stop before the distal growth plate. Proximally the nail should be
flush with the greater trochanter.
Proximal locking

Insert the proximal locking screw first.

Usually the nail has several options for proximal locking screws. Here the insertion
of a standard static locking screw is shown.
Assessment of rotational alignment

Before insertion of the distal locking screws assess rotational alignment by clinical
examination.

It is difficult to assess rotation with a plain x-ray and whilst anatomical reduction
of the fracture is a reasonable indicator, it should not be used as a surrogate for
careful clinical evaluation.

For more detail see the additional material on assessment of rotation .

In this example, the knee is placed in the true AP position and the appearance of the
lesser trochanter is compared with the uninjured limb.

Correction of length

Prior to insertion of distal locking screws ensure the femoral length is correct. If the
fracture is distracted, this is corrected by removing traction and impacting the
fracture.
Distal locking

Insert distal locking screws using a free-hand technique:

1. Align the nail to the image intensifier so that the screw hole forms a perfect circle.
2. Make a stab incision over the screw hole.
3. Exactly superimpose the point of the drill to the center of the locking screw hole.
4. Pass the drill through the near cortex, and through the screw hole before engaging the opposite cortex.
5. Uncouple the drill sleeve and check position with an image intensifier.
6. Complete drilling the far cortex.
7. Insert a bicortical screw.
End caps

Insert an end cap to facilitate access for later removal.

8. Final assessment
Check the range of internal and external rotation of the leg and compare with the
contralateral limb.

Obtain final AP and lateral fluoroscopic views.

9. Aftercare

Immediate postoperative care

The patient should get out of bed and begin ambulation with crutches on the first
postoperative day.

In most cases full weight bearing is permitted. With unstable fractures the patient
may begin with partial weight bearing.
Analgesia

Routine pain medication is prescribed for 3–5 days postoperatively.

Neurovascular examination

The patient should be examined frequently, to exclude distal neurovascular

compromise.

Compartment syndrome, although rare, should be considered in the presence of

severe swelling, increasing pain, and changes to neurovascular signs.

Discharge care

Discharge from hospital follows local practice and is usually possible after 1–3
days.

Mobilization

The patient should ambulate with crutches and begin knee range-of-motion
exercises.

Follow-up

The patient is usually reviewed 2 weeks after surgery for clinical and radiographic
assessment, and wound check.
Clinical assessment of leg length and alignment is recommended at one-year.

Clinical assessment of leg length uses a tape measure from the ASIS to the medial
malleolus.

If there is any concern about leg length discrepancy or malalignment, long-leg x-

rays are recommended.

Leg length is measured from the femoral head to the ankle joint.
Implant removal

If the patient develops symptoms related to the implant, it can be removed once the
fracture is completely healed, usually 6–12 months following injury.
 AO Surgery Reference

Pediatrics

(Femoral Shaft)

Positioning , Approaches &

Techniques
( Zaky Ortho )

1. Preoperative preparation
2. Spica casting
3. Patient preparation in supine position
4. Lateral approach to the pediatric femoral shaft
5. Assessment of rotation
6. ESIN entry points in the pediatric femur for antegrade nailing
7. ESIN entry points in the pediatric femur for retrograde nailing
8. Patient preparation in lateral position
9. Neurovascular anatomy
10. Safe zones for pin placement in the pediatric femur
11. Entry point in the pediatric femur for lateral-entry intramedullary nailing
12. Modular external fixation
13. Minimally invasive osteosynthesis approach to the pediatric femoral shaft
Preoperative preparation
1. Introduction
The outcome of surgery is strongly influenced by effective preoperative planning
and preparation of the patient and operating room personnel (ORP).

2. Patient information
Before treatment discuss the following information with the
patient/parents/caregivers:
Nature of the injury
The chosen treatment and why a particular treatment is selected
Alternative treatments
General operative risks
Expected healing time
Functional recovery
Implant removal
Possible complications

3. Information for operating room personnel

Operating room personnel (ORP) need to know and confirm:
Consent form, completed and signed
Site and side of fracture
Type of operation planned
Surgical approach
Operative site marked by surgeon
Condition of soft tissues
Equipment/implants needed
Patient positioning
Duration of operation
Positioning of image intensifier
Antibiotic prophylaxis
Comorbidities, including allergies

4. Surgical planning
The surgeon should ensure that:
Relevant x-rays and other images are available in the OR
Required instruments and implants are accessible and ready
Image intensification is available
There is a clear, step-by-step plan of the operation, including backup plans
Intraoperative x-ray documentation should be undertaken, with clear AP and lateral views, before
leaving the OR
Spica casting
1. General considerations

Single-leg, one-and-a-half-leg, or two-leg spica

Whilst a single-leg spica is adequate for most circumstances; some surgeons prefer
to extend the cast to the uninjured side as this can help to provide more stability,
especially in young children.

Complications
Loss of reduction
Compartment syndrome
Pressure sore

Pitfall: compartment syndrome

Take care not to use excessive force during the casting procedure. Avoid putting too much pressure
on the cast while holding the reduction.
It is also important to avoid flexion of the hip and knee beyond 90° as extremes of flexion are
associated with an increased risk of compartment syndrome.
2. Material and equipment

Material
Tubular bandage (stockinette) sized both for leg and for body
Cast padding
Felt
Casting material: fiberglass or plaster of Paris
Equipment
Hip spica box or table
Folded towel as abdominal spacer
3. Patient preparation
Read the additional material on preoperative preparation .

Dressing

Cut a generous length of tubular bandage to dress the injured leg and a larger
diameter tube for the torso. Tape the two parts of the tubular bandage together to
prevent separation of the bandages as the child is moved.

Place the back support for the spica box against the patient's skin underneath the
tubular bandage.
Placement on hip spica box

Transfer the anesthetized child onto the hip spica box. Make sure that enough
people are available to help positioning and stability.

The child’s sacrum should rest on the back support with its perineum against the
padded post. The shoulders should be supported by the spica box leaving almost
the entire torso free for casting.

The back support can be secured to the apparatus with tape.

Pitfall: Avoid inadvertent extubation during transfer and casting. Discuss airway management with
the anesthetist beforehand.
4. Single-leg spica

Dressing

Place a folded towel over the central abdomen, inside the tubular bandage, to create
space in the cast for breathing. Bring the tail of the towel towards the neck for ease
of removal.
Padding

Apply a layer of cast padding, using a larger width for the body and a narrower one
for the leg.

The cast extends from the nipple line, or just below, to just above the malleolus of
the ipsilateral ankle.

Consider adding thick felt over the padding at the free edges of the chest and leg.
Cast application

Apply a first layer of cast material to the leg and body sections, taking care to
connect leg to body securely, in a figure of eight (spica technique).

Pitfall: While not common, compartment syndrome may occur after application of a spica cast. The
cast should therefore end above the ankle to allow evaluation of pulses and foot and ankle
movement.
Reinforcing slabs of casting material may be applied between the body and leg
segments.

Finalizing the cast

Fold the tubular bandage and padding over the edges before applying the final layer
of casting material.

Once the cast material is hardened transfer the child from the spica box and remove
the abdominal towel and the back support from the cast.

Trim the edges of the cast, to allow flexion of the opposite hip and adequate access
to the perineal area.

Consider adding waterproof adhesive tape to the perineal edge of the cast.
Splitting the cast

If the cast around the abdomen has been applied too tightly, split it down the side
and spread to allow for expansion or remove and reapply it.

5. One-and-a-half- and two-leg spica

One-and-a-half- and two-leg spicas are applied in the same way as the single-leg
spica with the cast, on the contralateral leg, extended to the knee or ankle.

Apply reinforcing slabs of casting material across the hip region of both legs.

Option: bar

Consider the addition of a bar between the two legs to provide more stability to the
cast.
Patient preparation in supine position
1. Introduction
Most procedures can be performed with the limb free, prepped and draped from
groin to toes. ALFN is usually performed on a traction table with the draping
modified accordingly.

2. Preoperative preparation
Read the additional material on preoperative preparation .

3. Anesthesia
General anesthesia
Local nerve block in addition to pain management
Combination of nerve block and light general anesthesia

4. Prophylactic antibiotics
Antibiotics are administered according to local antibiotic policy and specific
patient requirements.

Many surgeons use Gram-positive prophylactic antibiotic cover for operative

management of closed fractures, adding Gram-negative prophylactic cover for
open fractures.
Antibiotic therapy will never compensate for poor surgical technique.

5. Clinical assessment of rotation of the femur

Prior to patient preparation and draping, examine the opposite intact femur to
determine the rotational range-of-motion.

If the patient is supine, demonstrate femoral rotation with the hip and knee each
flexed to 90°.

Internally and externally rotate the femur and record the maximum range.

6. Patient and C-arm positioning

Place the patient supine on a radiolucent fracture table with a sheet placed around
the pubic bone for countertraction.

A small support on the ipsilateral buttock may be helpful to stabilize the pelvis
during the procedure.
The C-arm comes in from the uninjured side.

As an alternative for ALFN, the patient may be placed on a traction table with a
unilateral leg support for optimal radiographs in AP and lateral views.

When positioning the patient check the rotational alignment of the uninjured femur.
Indirect reduction takes place by traction.

The C-arm comes in from the uninjured side.

7. Skin preparation and draping

Prepare the entire leg down to the foot.

Drape the entire leg up to the pelvis with the foot placed in a sterile bandage. If
using a radiolucent table, consider also preparing and draping the uninjured side for
intraoperative comparison of rotational alignment.

Drape the C-arm in a conventional manner.

For ALFN, prepare the entire leg down to the foot.

Drape the operative field with a plastic occlusion drape with the foot placed in the
traction device.

Drape the C-arm in a conventional manner.

8. OR set-up
The optimal position of the surgeon is on the injured side of the patient.

The position of the screen should allow a direct view for the surgeon.

OR set-up for ALFN

Lateral approach to the pediatric
femoral shaft
1. Introduction
Open procedures use an incision on the lateral aspect of the thigh.

2. Principles
The major vessels and nerves are located medially/posteromedially to the femoral
shaft and are not exposed using this approach.
3. Skin incision
Perform an incision along a line between the lateral femoral epicondyle and the
greater trochanter, along the length of the femur determined by the specific fracture
pattern.
4. Opening the fascia lata
Incise the fascia lata with a scalpel and split it with scissors parallel to the skin
incision, along its fibers.

Expose the fascia over the vastus lateralis.

5. Principles of a safe approach

As the fibers of origin of the vastus lateralis are elevated from the intermuscular
septum, identify the perforating vessels and protect or ligate them.

If divided close to the septum, the proximal ends can retract into the posterior
compartment of the thigh, causing troublesome occult bleeding.
6. Separation of vastus lateralis from fascia lata
Separate the vastus lateralis from the fascia lata using blunt dissection.

7. Incision of the fascia vastus lateralis

Retract the vastus lateralis anteromedially.

Incise the fascia investing the vastus lateralis 1 cm anterior to the intermuscular
septum.

8. Mobilization of vastus lateralis from intermuscular septum

Detach the muscle from the lateral intermuscular septum and the linea aspera with
a periosteal elevator.
9. Control of perforating vessels
Identify the perforating vessel bundles.

These vessels perforate the lateral intermuscular septum from the posterior side and
run anteriorly, remaining closely applied to the femoral shaft.

In children these vessels can be cauterized with the diathermy.

10. Exposure of the bone
Using the elevator, continue extraperiosteal detachment of the vastus lateralis to
expose the femoral shaft.

11. Exposure of the proximal femoral shaft

If exposure of the proximal femoral shaft is necessary, identify the origin of the
vastus lateralis.

Retract the muscle anteriorly and perform an L-shaped incision down to the bone.
The transverse part of the incision lies in the interval between gluteus medius and
vastus lateralis.

Dissect the muscle from its origin using a periosteal elevator.

12. Closure
Return the vastus lateralis to its original position over the lateral femur. Repair the
origin and close the tensor fascia lata.

The subcutaneous tissue and skin are closed according to surgeon’s preference.
Assessment of rotation
1. Introduction
Confirm rotational alignment of the femur clinically and radiographically before
finalizing fixation. This can be done by:
Direct visualization of fracture site if open
Fluoroscopy of fracture site
Comparing internal and external rotation to the contralateral side
Fluoroscopy of proximal femur (lesser trochanter profile and/or matching the cortices of both sides of
the fracture)

2. Clinical assessment of rotation of the femur

Prior to patient preparation and draping, examine the opposite intact femur to
determine the rotational range-of-motion.

If the patient is supine, demonstrate femoral rotation with the hip and knee each
flexed to 90°.

Internally and externally rotate the femur and record the maximum range.

After reduction and (provisional) fixation of the fractured femur, examine internal
and external rotation. They should be similar to the preoperative findings on the
opposite side.
3. Fluoroscopy assessment of the lesser trochanter profile
Compare the profile of the lesser trochanter on the intensifier image with that of the
contralateral leg (lesser trochanter shape sign).

Before positioning the patient, store the profile of the lesser trochanter of the intact
opposite side (patella facing anterior) in the image intensifier.

The illustration shows the lesser trochanter of the intact opposite side.
Malrotation

In cases of malrotation, the lesser trochanter is of different profile when compared

to that of the contralateral leg.

Care should be taken to assess rotation with the patella facing directly forwards.

This illustration shows internal malrotation of the proximal fragment.

This illustration shows external malrotation of the proximal fragment.

Matching of the lesser trochanter shape

When rotational alignment is correct, the lesser trochanter profile will match that of
the opposite side when the patella is facing forwards.
4. Fluoroscopy assessment of the cortical congruency across
fracture site
The appearance of the cortices across the fracture site is checked under image
intensification.

Cortical thickness and shaft diameter should match.

ESIN entry points in the pediatric femur
for antegrade nailing
1. General considerations
For fracture patterns stabilized with the ESIN technique using an antegrade
approach and two elastic nails, the entry points are in the lateral proximal femur.

The usual entry points are 0.5–1 cm distal to the greater trochanteric growth plate.

Entry points should be at least 2 cm apart in the axial plane and at least 1 cm apart
in the lateral plane. If they are too close, the cortex may split during the insertion of
the nails.

There is a lower risk of iatrogenic fracture if both entry points are made in the
metaphyseal bone proximal to the lesser trochanter. Alternatives include entry
points in the lateral aspect of the greater trochanter.

2. Skin incision
Make a 3–5 cm skin incision in the lateral aspect of the trochanteric region. The
incision extends proximally from the entry points to allow sufficient space to
advance the nails at an angle to the cortex.
3. Deep dissection
Spread the fascia and muscle to expose the lateral cortex of the femur just below
the greater trochanter.

4. Wound closure
After careful hemostasis, close the skin and subcutaneous tissues in a routine
manner.
ESIN entry points in the pediatric femur
for retrograde nailing
1. General considerations
For fracture patterns stabilized with the ESIN technique using a retrograde
approach and two elastic nails, the entry points are at the same level in the distal
femur on the lateral and medial side.

The entry points are 2–3 cm proximal to the growth plate, in the middle of the
femoral shaft in the sagittal plane.

2. Skin incision
Make a 3 cm skin incision starting at the entry point and extending distally. This
allows sufficient space to advance the nails at an angle to the cortex.
3. Deep dissection
Spread the fascia and muscle to expose the cortex of the femur.

4. Wound closure
After careful hemostasis, close the skin and subcutaneous tissues in a routine
manner, preferably with resorbable sutures.
Patient preparation in lateral position
1. Introduction
The lateral position provides good access to the greater trochanter for nailing.

Gravity displaces the soft tissues away from nail entry site.

2. Preoperative preparation
Read the additional material on preoperative preparation .

3. Anesthesia
General anesthesia
Local nerve block
Combination of nerve block and light general anesthesia

4. Prophylactic antibiotics
Antibiotics are administered according to local antibiotic policy and specific
patient requirements.

Many surgeons use Gram-positive prophylactic antibiotic cover for operative

management of closed fractures, adding Gram-negative prophylactic cover for
open fractures.
Antibiotic therapy will never compensate for poor surgical technique.

5. Clinical assessment of rotation of the femur

Prior to patient preparation and draping, examine the opposite intact femur to
determine the rotational range-of-motion.

If the patient is supine, demonstrate femoral rotation with the hip and knee each
flexed to 90°.

Internally and externally rotate the femur and record the maximum range.

6. Patient position
The patient is placed in a lateral position and securely held with props on the
lumbar spine and the anterior superior iliac spine (ASIS).

The contralateral shoulder must be carefully positioned to prevent brachial plexus

injury.

Bolsters, pads or a bean bag can be used to support the pelvis anteriorly and
posteriorly.
7. C-arm positioning
Adjust the table and C-arm so that AP and lateral views can be obtained.

Position the C-arm perpendicular to the operating table.

8. Skin preparation and draping
Fully prepare and drape the leg.

Drape the C-arm of the image intensifier completely.

9. OR set-up
The optimal position of the surgeon is behind the patient with the operated leg
slightly flexed and adducted to provide access to the femoral intramedullary canal.

The position of the screen should allow a direct view for the surgeon.
Neurovascular anatomy
1. Vascular anatomy of the proximal femur
The deep branch of the medial femoral circumflex artery (MFCA) provides the
main relevant blood supply to the femoral head. Maintaining this blood supply is
vital in the skeletally immature patient.

The MFCA originates from the deep femoral artery (profunda femoris), courses
between the iliopsoas and pectineus muscles, and runs posteriorly between the
femur and the pelvis.

The main branch of the MFCA is related to the inferior border of the obturator
externus muscle and passes posterior to the femur, towards the intertrochanteric
crest.
It then crosses posterior to the obturator externus and anterior to the triceps coxae
(obturator internus and the superior and inferior gemelli).

Before crossing the triceps coxae, a small branch passes to the greater trochanter.

The vessel enters the joint capsule between the gemellus superior and the
piriformis muscles.

Note: In the nailing of adolescent femoral shaft fractures the lateral greater trochanteric start point is
used to minimize the risk of avascular necrosis by avoiding injury to the MFCA.
After perforating the capsule, the vessel passes along the superior retinaculum and
splits into 3–4 branches.

2. Neurovascular anatomy of the femoral shaft

The diaphysis of the femur is surrounded by a thick muscular envelope. The major
neurovascular structures are located medially and, therefore, the femur can be
safely approached from laterally. The internervous plane lies along the posterior
border of vastus lateralis.

3. Neurovascular anatomy of the distal femur

The popliteal artery lies directly behind the distal femoral metaphysis. Therefore, it
may be at risk during anteroposterior screw insertion.
Safe zones for pin placement in the
pediatric femur
1. Introduction
The safest anatomical zones for pin insertion are the anterolateral and direct lateral
regions of the femur.

2. General considerations

Anatomy

The thigh is covered by a circumferential muscular envelope and the diaphysis of

the femur by a thick periosteum.

The major neurovascular structures are located medially and, therefore, the femur
can be safely approached over the anterolateral region.
Overall neurovascular status of the limb

For the pin insertion, consider the state of the soft-tissue envelope of the femoral
shaft (areas of skin loss or extensive soft-tissue damage should be avoided, to
minimize the risk of subsequent pin-track infection).

Conversion of temporary external fixator to nailing or plating

Take care to protect the skin and soft tissues during pin insertion, whether the
external fixator is to be used as a definitive device or substituted for an
intramedullary nail or plate at a later stage.

3. Safe zone in the proximal third

With the patient supine, palpate the greater trochanter and, depending on the
fracture configuration, direct the pin through vastus lateralis, aiming towards the
lesser trochanter (A) …
… or the femoral neck (B).

Ensure that the entry points for pin insertion will not subsequently conflict with the
conversion of the external fixator to an intramedullary nail.

The safe zone for pin placement includes the area from just behind the anterior
margin to the posterior margin of the lateral face of the greater trochanter.
4. Safe zone in the midshaft
The anatomy in the area between the two solid lines is represented by one cross-
section and does not vary significantly at different levels within this zone.

The direct lateral approach is preferred because it interferes the least with knee
motion.
Direct lateral approach (C)

Palpate the vastus lateralis and insert the pins in the direction shown in the
diagram, aiming to obtain purchase in both cortices.

Anterolateral approach (D)

Palpate vastus lateralis and rectus femoris with the patient in supine position. The
direction of the pin should be in the plane between these two muscles, as shown in
the cross-section illustration. Take care to avoid perforation beyond the femoral
cortex medially to prevent injury to the neurovascular structures.

5. Safe zone in the distal third

Direct lateral approach (E)

The lateral area of the distal femur is easily accessible for pin insertion. The
inferior border of vastus lateralis is the only soft-tissue structure to avoid.

The pin should be positioned at least 2 cm proximal to the growth plate.

Entry point in the pediatric femur for
lateral-entry intramedullary nailing
1. Introduction
The nail entry point lies on the lateral surface of the greater trochanter.

2. Skin incision
The skin incision is centered on the palpable tip of the greater trochanter and
extends 3 cm proximally, and distally as required.

The incision should be in line with the medullary canal on the lateral view, which
can be marked on the skin using the lateral image intensifier view.
3. Deep dissection
Incise the fascia lata in the same direction to expose the underlying greater
trochanter.

4. Determination of entry point

The entry point of the nail lies lateral and inferior to the tip of the greater
trochanter. This can be clearly seen on an AP image-intensifier view.

Carefully palpate the anterior and posterior borders of the greater trochanter to
identify its center.

5. Wound closure
Close the wound in a standard manner.
Modular external fixation
1. Principles

Modular external fixator

The modular external fixator may be used for temporary or definitive stabilization.
It is rapidly applied without need for intraoperative x-rays and can be adjusted
later.

The fixator consists of two partial frames (a, b), one on each main fracture
fragment. Each partial frame starts with two pins in a bone fragment, connected
with a rod. The two frames are joined with a rod-to-rod construction/connecting
rod (c).

This allows manipulation and reduction of the fracture after pin placement and
guarantees sufficient stiffness of the frame. It also allows pins to be inserted
through safe zones, avoiding the zone of injury.

Optimal frame construction

For the construction of the frame consider the following points:

Pins are placed near the fracture site, but not too close and avoiding the zone of injury (a).
Pins are widely separated in each main fracture fragment (b).
 Rods are connected to the pins with rod-to-pin clamps (c).
The rod-to-pin clamps are fully tightened so that each main fragment has its own partial frame.
In bones with small diameter it may be helpful to insert the pins in an oblique manner (d) for better
pin-bone contact.

The two partial frames are joined using a connecting rod.

The clamps are first provisionally tightened with a T-handle and then fully tightened using a wrench.

The stiffness of the frame may be increased by the following options:

 Using thicker pins
Positioning the rod closer to the bone
Adding a second connecting rod (neutralization rod) (e) between the partial frames
Inserting additional pins in each segment

Equipment needed

The following components are needed to construct a large external fixator (the
principles for smaller sets are the same):
1. Threaded pins (Schanz type pins, standard or self-drilling/self-tapping with radial preload
2. Carbon fiber rods or metal tubes
3. Rod-to-pin clamps (titanium, MRI safe)
4. Combination clamps (rod-to-rod or rod-to-pin, self-holding, titanium, MRI safe)
5. Rod-to-pin clamps (old type, still in use)
6. Rod-to-rod clamps (old type, still in use)

Selection of a large, medium, small, or mini external fixator depends on the age,
anatomic region, and bone size.

The pins, rods and clamps are similar in all systems, but vary in dimensions.

Recommended pin diameters:

2.5–4.0 mm for upper extremity
3.0–6.0 mm for lower extremity

Recommended rod/tube diameters:

4 mm for small external fixator
8 mm for medium external fixator
11 mm for large external fixator
Additional components may be needed for the application of more sophisticated
frames.

2. Pin insertion

Pin placement

Two pins should be inserted in each of the proximal and distal fragments in the safe
zones.

The risk of tendon penetration or injuries to nerves, vessels, and muscles is

determined by the anatomy of each region. Pins should not be placed where they
will enter a joint cavity or growth plate. This is described in the relevant section.

The use of an image intensifier is recommended to facilitate optimal and safe pin
placement.

In temporary external fixation, the pins should be placed so that they do not
interfere with planned definitive fixation.
Skin incision

The position of each skin incision is determined by the pin position. As the fracture
is reduced, skin movement in relation to the pin should be anticipated. The incision
may be extended to release any skin tension.

Predrilling

Unless self-drilling pins are to be used it is essential to predrill both cortices prior
to the insertion of threaded pins. This is not necessary for pins up to 4 mm.

The drill should be cooled to prevent thermal bone necrosis.

Place a drill sleeve with trocar through the prepared soft-tissue channel to prevent
damage to soft tissues. The use of an image intensifier may be beneficial to
determine correct pin trajectories.

Note: When self-drilling 2.5–4.0 mm Schanz screws are used, predrilling is not recommended.
Pin insertion (conventional threaded pins)

Insert conventional pins by hand using the corresponding drill sleeve.

Ensure that the pin includes both cortices; feeling the pin thread engage the
opposite cortex confirms correct insertion depth.

It is recommended that the position of all pins is confirmed in two planes using an
image intensifier.
Threaded pins should be inserted so that the thread of the pin is fully engaged in
the predrilled hole of the far cortex.

Over penetration of the pins should be avoided as this endangers the soft tissues.

Pin insertion (self-drilling Schanz screws)

Insert each pin through the drill sleeve. A power tool is used to insert the screw
thought the near cortex. Once the screw reaches the far cortex, which can be felt
easily, turn the pin manually for another one or two rotations to anchor the tip of
the screw in the inner side of the far cortex.

This configuration only applies for self-tapping self-drilling pins.

Self-drilling and self-tapping pins must not perforate the far cortex (the protruding
sharp tip can cause soft-tissue injury if it projects beyond the cortex).
3. Frame construction

Frame assembly

Connect the two pins of each main fragment to a rod using rod-to-pin clamps.

The rod should lie close to the skin, but with sufficient clearance to accommodate
subsequent swelling.

There should be enough room between the rod and skin to allow cleaning.

Fully tighten the rod-to-pin clamps to complete the two partial frames.
Connect the two partial frames with a rod using rod-to-rod clamps applied loosely
enough to allow reduction of the fracture.

Pearl: shortening the pins

 To improve patient comfort, shorten the pins to leave 1 cm protruding from the clamp and protect the
sharp ends.

Pitfall: conflicting rods

The ends of the two rods should not be placed too close to each other as this could interfere with
reduction.
4. Reduction and fixation

Reduction

Using the partial frames as handles, manually reduce the fracture in length, rotation
and axis.

Check the provisional reduction in AP and lateral views with an image intensifier if
available.

Note: The fracture should always be brought out to length and reduced as accurately as is practical.
This protects the soft tissues and enables a planned temporary external fixator to be used for
definitive fixation.
Pearl: lengthening the lever arm

When strong force is required to achieve reduction, it may be helpful to temporarily add rods to each
partial frame to lengthen the lever arm.
These rods may be attached in whatever orientation is most convenient.
It is then easier to apply the force necessary for reduction and allows the surgeon’s hands to remain
outside the image intensifier beam.
Fixation

When satisfactory reduction has been obtained, tighten the rod-to-rod clamps to
finalize the frame construction. Reconfirm reduction with the image intensifier.
If additional stability is needed to secure the reduction, attach an additional rod
(neutralization rod) to the two partial frames.

This may be attached at each end to either a rod or a pin.

A curved rod or two connecting rods may be used.

Periarticular injuries

When the fracture lies close to a joint it may be necessary to stabilize small
periarticular fragments with a joint-spanning frame.

In fractures with long healing times this should be converted to a form of fixation
which allows the joint to move as soon as is practical, otherwise there is a risk of
long-term stiffness.

Associated fractures

In a limb with fractures at more than one site, where both fractures are treated with
an external fixator, it may be helpful to join the two frames (eg ipsilateral femoral
and tibial fractures).

Inspection and treatment of skin incisions

After the operation, stab incisions should be left open and treated with antiseptic
dressings. Closing stab incisions prevents wound drainage, which increases the risk
of pin-track infection.
If there is skin tension on one side, the incision should be extended. If significant
extension is required so that the total incision is unnecessarily long the redundant
portion of the incision may be closed.

5. Subsequent management after external fixation as temporary

fixation
If external fixation was used because the patient was not fit or had a severe soft-
tissue injury, definitive fixation may be considered once the general or local
conditions have improved.

In children definitive fixation may be with a cast if callus formation is visible.

Healed soft tissues

If the soft-tissue injuries have healed without pin-track infection, the external
fixator can be removed and replaced with appropriate stabilization such as internal
fixation or a cast.

It should be noted that every pin is colonized after a few days.

Soft-tissue problems persist

Changing to definitive internal fixation in the presence of pin-track infection is

associated with an increased risk of implant infection.

If soft-tissue problems persist or there are pin-track infections the following steps
should be taken:
 Remove the external fixator.
Debride the pin sites in the operating theater, using curettage and irrigation, taking specimens for
microbiological study.
Temporarily stabilize in a splint or cast or place a new external fixator with pins at new sites.
Let the initial pin tracks heal.
Proceed with internal fixation, covering with antibiotics as determined by positive microbiological
cultures or local protocols.

Pitfall: intramedullary infection

Using an intramedullary nail after a recent pin-track infection risks diaphyseal spread of infection
and should be avoided.

6. External fixation as definitive fixation

Indications

In children, fracture healing is often rapid. If external fixation is initially chosen, it

could remain until fracture healing.

Adjusting the fixator

A temporary external fixator may be applied rapidly in a severely injured patient.

If external fixation is subsequently chosen as the definitive treatment, the fixator

can be adjusted to produce more secure fixation.

It may be necessary to apply a new construct to maintain stable reduction until the
fracture has healed.

Pitfall: pin loosening or pin-track infection

In case of pin loosening or pin-track infection, the following steps should be taken:

Remove all involved pins and place new pins in a healthy location.
Debride the pin sites in the operating theater, using curettage and irrigation.
Take specimens for a microbiological study to guide appropriate antibiotic treatment
complementing the surgical debridement.
Minimally invasive osteosynthesis
approach to the pediatric femoral shaft
1. Introduction
Approaches for minimally invasive plate osteosynthesis are usually performed
laterally. They vary according to the fracture location: proximal, midshaft, or distal.

2. Principles
The advantages of minimally invasive plate osteosynthesis of the femoral shaft
include reducing the extent of muscle detachment and limiting the effect on bone
vascularity.

Approaches for minimally invasive plate osteosynthesis are usually performed

laterally.

A minimum of one small incision to approach the bone is required to place the
plate.

A distal approach is most commonly used for fractures in the distal third of the
shaft.
A proximal approach is most commonly used for fractures in the proximal third of
the shaft.

Midshaft fractures can be approached from either end and the position of the
incision can be moved towards the fracture providing better access to the diaphysis.

Additional screws can usually be placed through stab incisions. In some cases, a
second small approach is required at the fracture site or at the far end of the plate to
allow direct manipulation.

Thorough preoperative planning is compulsory to define the location of the most

suitable approach.

3. MIO approach to the distal femur

Perform a lateral incision as far as the femoral epicondyle distally.

The starting point and length of the incision can be adapted to suit operational
requirements.
Incise the fascia lata and split it along its fibers, parallel to the skin incision.

Mobilize the inferior margin of the vastus lateralis and retract the muscle anteriorly.
The plane between the femur and vastus lateralis is the entry point for the plate.
Closure

Allow the vastus lateralis to fall back over the plate and femur and close the tensor
fascia lata.

The subcutaneous tissue and skin are closed according to surgeon’s preference.

4. MIO approach to the subtrochanteric region

Start the lateral proximal incision at the greater trochanter and continue distally as
far as needed.
Incise the fascia lata with a scalpel and split it with scissors, parallel to the skin
incision.

Expose the fascia over the vastus lateralis.

If exposure of the proximal femoral shaft is necessary, identify the origin of the
vastus lateralis.

Perform an extraperiosteal L-shape incision and retract the muscle anteriorly.

Elevate the vastus lateralis sufficiently to allow submuscular plate insertion.

Closure

Repair the origin of vastus lateralis and close the tensor fascia lata.

The subcutaneous tissue and skin are closed according to surgeon’s preference.

5. MIO approach to the femoral shaft

Perform a short incision along a line between the lateral femoral epicondyle and the
greater trochanter.

The starting point and the length of the incision depend on the operational
requirements for the minimally invasive procedure.

Incise the fascia lata and expose the fascia of the vastus lateralis.
Incise the fascia of the vastus lateralis.

This small lateral incision provides enough access without devascularization of

muscle.
Perform blunt dissection directly through the belly of the vastus lateralis to the
bone.

The use of one anterior and one posterior extraperiosteal Hohmann retractors is
recommended for exposure of the femoral shaft. These retractors also assist with
accurate plate positioning on the femur.
Closure

Allow the vastus lateralis to fall back over the top of the lateral femur and close the
tensor fascia lata.

The subcutaneous tissue and skin are closed according to surgeon’s preference.