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Pediatric Femoral ShaftPediatric Femoral Shaft
FracturesFractures
Dr. Tahir MahmoodDr. Tahir MahmoodLahore General HospitalLahore General Hospital
LahoreLahore
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Pediatric Femur FracturesPediatric Femur Fractures
1.6 % of all children Fractures1.6 % of all children Fractures
28/100,000 child per year 28/100,000 child per year
3:1 Male / Female ratio3:1 Male / Female ratioChildren >3 yrs- highest incidenceChildren >3 yrs- highest incidence
Seasonal- highest summer Seasonal- highest summer
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Anatomy and GrowthAnatomy and Growth
Proximal femoralProximal femoral physis- 30% of physis- 30% of longitudinal growthlongitudinal growth
Distal femoral physis-Distal femoral physis-70% of longitudinal70% of longitudinalgrowthgrowth
Rapid increase inRapid increase incortical thicknesscortical thickness
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Pediatric Femur Fractures-Pediatric Femur Fractures-Mechanism of InjuryMechanism of Injury
Rule out child abuseRule out child abuse
Falls- young children/toddlersFalls- young children/toddlers
Struck by vehicle- juvenileStruck by vehicle- juvenile
Recreational sports/activities- adolescentRecreational sports/activities- adolescent
Motor vehicle crashes- all age groupsMotor vehicle crashes- all age groups
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Mechanism of InjuryMechanism of Injury
Low EnergyLow Energy
High EnergyHigh Energy
* predicts predicts behavior/treatment of behavior/treatment of the fracturethe fracture
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Pediatric Femur Fractures-Pediatric Femur Fractures-Associated InjuriesAssociated Injuries
Struck by car- triad of femur fracture, torsoStruck by car- triad of femur fracture, torsoinjuries, head injuryinjuries, head injury
Potential damage to physis of femur andPotential damage to physis of femur and proximal tibia proximal tibia
Head Injury spasticity can make traction andHead Injury spasticity can make traction andcast treatment difficultcast treatment difficult
Abdominal injury spica cast can constrictAbdominal injury spica cast can constrictabdomen and limit ability to examineabdomen and limit ability to examine
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Spasticity Leading to ExtremeSpasticity Leading to ExtremeAngulation and ShorteningAngulation and Shortening
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Physical ExamPhysical Exam
Complete exam: head, chest, abdomen, andComplete exam: head, chest, abdomen, andother skeletal segmentsother skeletal segments
Document distal neurological and vascular Document distal neurological and vascular functionfunction
Palpate all bonesPalpate all bones
First Aid principles - Splint or traction,First Aid principles - Splint or traction,especially prior to transfer to another especially prior to transfer to another institutioninstitution
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Radiographic EvaluationRadiographic Evaluation
AP PelvisAP Pelvis
AP/Lat femur AP/Lat femur
Visualize hip & kneeVisualize hip & knee joints joints
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ClassificationClassification
Fracture patternFracture patterntransverse, spiral, oblique, comminuted, greenstick transverse, spiral, oblique, comminuted, greenstick
Amount of shorteningAmount of shorteningAngular deformityAngular deformityOpen / closedOpen / closed
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7 Principles7 PrinciplesDameron & ThompsonDameron & Thompson
1. Simplest treatment best1. Simplest treatment best
2. Initial treatment permanent when possible2. Initial treatment permanent when possible
3. Perfect anatomic reduction not essential for 3. Perfect anatomic reduction not essential for perfect function perfect function
4. More potential growth= more remodeling4. More potential growth= more remodeling
capabilitycapability
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7 Principles7 PrinciplesDameron & Thompson JBJS 1959Dameron & Thompson JBJS 19595. Restoration of alignment more important5. Restoration of alignment more important
than fragment positionthan fragment position
6. Over treatment usually worse than under 6. Over treatment usually worse than under
treatmenttreatment
7. Immobilize/splint injured limb before7. Immobilize/splint injured limb beforedefinitive treatmentdefinitive treatment
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Treatment Goals - RestoreTreatment Goals - Restore
LengthLength
AlignmentAlignmentRotationRotation
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Treatment Goals - AvoidTreatment Goals - Avoid
Osteonecrosis - disruption of blood supplyOsteonecrosis - disruption of blood supplyto femoral headto femoral headPhyseal injury- preserve future growthPhyseal injury- preserve future growth
potential (proximal and distal femoral potential (proximal and distal femoral physis, trochanteric apophysis) physis, trochanteric apophysis)
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Complication of fracture femurComplication of fracture femur
Leg lengthLeg lengthdiscrepancydiscrepancy
shorteningshortening
over growthover growthAngular deformityAngular deformityRotational deformityRotational deformity
Delayed unionDelayed union
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Complication of fracture femurComplication of fracture femur
Non union Non union
Muscle weaknessMuscle weaknessInfectionInfection
Neurovascular injury Neurovascular injury
Compartment syndromeCompartment syndrome
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Decision MakingDecision Making
AgeAge
Mechanism of injuryMechanism of injury
Fracture pattern &Fracture pattern &locationlocationAssociated InjuriesAssociated Injuries
Surgeon preferenceSurgeon preference
Available resourcesAvailable resources
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Treatment optionsTreatment options
Age Treatment.Age Treatment.
Birth to 24 mo padding & soft splintBirth to 24 mo padding & soft splint
Pavlik harness (newborn to 6 mo)Pavlik harness (newborn to 6 mo)
Immediate spica castImmediate spica castTraction ~spica castTraction ~spica cast
2 yrs to 5 yrs Immediate spica cast2 yrs to 5 yrs Immediate spica cast
Traction ~ spica castTraction ~ spica cast
External fixation (rare)External fixation (rare)TEN (rare)TEN (rare)
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Treatment optionsTreatment options
6 yrs to 11 yrs Traction ~ spica cast6 yrs to 11 yrs Traction ~ spica cast
Compression plateCompression plate
TENTEN
External fixationExternal fixation
12 yrs to maturity TEN12 yrs to maturity TEN
Compression plateCompression plate
Locked IMNLocked IMNExternal fixationExternal fixation
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Acceptable angulationsAcceptable angulations
Age Varus/ Anterior/ ShorteningAge Varus/ Anterior/ Shortening
Valgus Posterior (mm)Valgus Posterior (mm)
(degrees) (degrees)(degrees) (degrees)Birth to 2yrs 30 30 15Birth to 2yrs 30 30 15
2-5 yrs 15 20 202-5 yrs 15 20 20
6-10 yrs 10 15 156-10 yrs 10 15 1511yrs to maturity 5 10 1011yrs to maturity 5 10 10
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Traction TechniquesTraction Techniques
Skin or skeletalSkin or skeletal
Longitudinal in line traction for comfort prior Longitudinal in line traction for comfort prior to definitive treatmentto definitive treatment
Longitudinal in line traction for comfort prior Longitudinal in line traction for comfort prior to definitive treatmentto definitive treatment
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Traction TechniquesTraction Techniques
Vertical over headVertical over headtraction hip flexed 90traction hip flexed 90
degree (Bryant 1973)degree (Bryant 1973)Split RussellsSplit Russellstraction (90-90) if traction (90-90) if awaiting earlyawaiting earlyhealing prior tohealing prior tocastingcasting
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Skeletal Traction TechniquesSkeletal Traction Techniques
Avoid physis if placeAvoid physis if placeskeletal traction pinsskeletal traction pins
Place pin perpendicular Place pin perpendicular
to shaft to avoidto shaft to avoidvarus/valgus angulationvarus/valgus angulation
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Subtrochanteric fracture treated with tractionSubtrochanteric fracture treated with tractionfollowed by one legged ambulatory spica castfollowed by one legged ambulatory spica cast
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Immediate Spica Cast-Immediate Spica Cast-ideal patientideal patient
Less than 5 years oldLess than 5 years old
Less than 50 lbsLess than 50 lbs
Initial shortening not excessiveInitial shortening not excessiveIsolated injuryIsolated injury
Note -Spica casts used for decades and can Note -Spica casts used for decades and canwork for almost any pediatric femur fracturework for almost any pediatric femur fracture
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Spica Cast TechniqueSpica Cast Technique
Appropriate paddingAppropriate paddingCast liners may decreaseCast liners may decreaseskin problemsskin problemsTraction to get 0-15 mmTraction to get 0-15 mmshorteningshorteningMold laterally to preventMold laterally to preventvarusvarusCan wedge forCan wedge for
unacceptable angulation atunacceptable angulation at1-2 week 1-2 week checkupscheckups
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Spica CastSpica Cast
Fiberglass lighter, easier Fiberglass lighter, easier to x-ray throughto x-ray through
Often strong enough toOften strong enough to
obviate need for obviate need for connecting bar connecting bar
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Sitting spica 3 part, 90-90Sitting spica 3 part, 90-90
This technique, recommended intextbooks and articles, may increaserisk of developing compartmentsyndrome
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Current technique Above knee cast first.Current technique Above knee cast first.Hip and knee- 40-45 flexion, foot out.Hip and knee- 40-45 flexion, foot out.Can include opposite thigh if desired.Can include opposite thigh if desired.
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Immediate Spica CastImmediate Spica Cast
X-ray weekly for 3X-ray weekly for 3weeksweeksTime in spica = age inTime in spica = age in
years + 3 weeks up toyears + 3 weeks up tomaximum 8 weeksmaximum 8 weeksWedge cast for Wedge cast for malalignmentmalalignment
Rotational alignmentRotational alignmentimportant at initial castimportant at initial castapplicationapplication
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ComplicationsComplications
Closed treatment of Closed treatment of childrens femur fractureschildrens femur fracturesresulted in the mostresulted in the most
frequent and expensivefrequent and expensivecomplications, includingcomplications, includingfoot drop, skin loss,foot drop, skin loss,compartment syndrome,compartment syndrome,
and malrotation /and malrotation /shortening.shortening.
C d li i lC d li i l
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Compartment syndrome complicating earlyCompartment syndrome complicating earlyspica cast treatment of isolated femoral shaftspica cast treatment of isolated femoral shaft
fractures in childrenfractures in children- JBJS Nov 03- JBJS Nov 03
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Mold into slightvalgus desired on
initial radiographafter casting
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Femoral Remodeling afterFemoral Remodeling afterFractureFracture
Will not correct significantWill not correct significantrotational malunionrotational malunion(Davids, Clin Orthop)(Davids, Clin Orthop)Overgrowth 1-1.5 cm mayOvergrowth 1-1.5 cm mayoccur, especially inoccur, especially inyounger children treatedyounger children treatednonoperativelynonoperativelyAngular deformity willAngular deformity willremodel significantly inremodel significantly inchildren 10years oldyears old
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Trend Toward MoreTrend Toward More
Invasive TreatmentInvasive TreatmentMore high energy fracturesMore high energy fractures
Improved operative techniquesImproved operative techniquesFailed nonoperative treatmentFailed nonoperative treatment
Simplifies patient careSimplifies patient carePsychological, social and financialPsychological, social and financial
reasonsreasons
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Ambulatory Treatment OptionsAmbulatory Treatment Options
Plate & screw fixationPlate & screw fixation
External fixationExternal fixation
Flexible nailingFlexible nailing
Rigid nailingRigid nailing
Bridge plating / MIPPO/ locked platesBridge plating / MIPPO/ locked plates
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Flexible NailingFlexible Nailing
AdvantagesAdvantagesAllows earlyAllows earlymobilization without castmobilization without cast
Cosmetic scarsCosmetic scarsAvoids physis and bloodAvoids physis and bloodsupply to femoral headsupply to femoral head
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12 yo male in RTA accidentClosed proximal third, oblique fractureBack at school 2 weeks
Walking at 8 weeks
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Flexible NailingFlexible Nailing
DisadvantagesDisadvantages
Ends may irritate softEnds may irritate softtissuestissues
May not be amenable toMay not be amenable tosome fracture patternssome fracture patterns(very proximal or distal,(very proximal or distal,comminution)comminution)
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Flexible NailsFlexible Nails
Titanium elasticTitanium elasticintramedullary nailingintramedullary nailing(TEIN)(TEIN)
popular choice to popular choice tostabilize pediatric femur stabilize pediatric femur fractures in children > 5fractures in children > 5yrsyrs
little published onlittle published oncomplicationscomplicationsJBJS Br 2006JBJS Br 2006
Healed 5 cm short
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Most complications minorMost complications minor
Nail Irritation (16%) -Nail Irritation (16%) -dont bend endsdont bend ends
- all resolved post- all resolved post
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Cut pins above physis with screwCut pins above physis with screwcuttercutter
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13yo male, 94 lbs -nails too short, back out, get13yo male, 94 lbs -nails too short, back out, getinfected, have to be removed, varus malunion withinfected, have to be removed, varus malunion with
shorteningshortening
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12 yr old female, 130 lbs12 yr old female, 130 lbsVarus, procurvatum malunionVarus, procurvatum malunion
TEIN i ld d ll t ti f t ltTEIN yielded excellent or satisfactory results
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TEIN yielded excellent or satisfactory resultsTEIN yielded excellent or satisfactory resultsin 90% of casesin 90% of cases
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Outcome was better in a higher percentage of Outcome was better in a higher percentage of central-third fracturescentral-third fractures
Be aware of prox 1/3- mid 1/3Be aware of prox 1/3- mid 1/3
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Be aware of prox 1/3- mid 1/3Be aware of prox 1/3 mid 1/3 junction fracture with medial junction fracture with medial
butterflybutterfly
Recommendations :Recommendations :
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Recommendations :Recommendations :> 11 years, > 108 lbs> 11 years, > 108 lbs
consider other treatment options consider other treatment options
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ORIF with Plates/ScrewsORIF with Plates/Screws
AdvantagesAdvantagesAnatomical reductionAnatomical reduction
Rigid fixationRigid fixation
Technique familiar to most surgeonsTechnique familiar to most surgeons
Allows early motionAllows early motion
Simplified nursing careSimplified nursing care
Favorable results reported in children withFavorable results reported in children withassociated head injuriesassociated head injuries
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ORIF with Plates/ScrewsORIF with Plates/Screws
DisadvantagesDisadvantagesLarge scar Large scar
Implant failureImplant failure
Possible refracture after plate removedPossible refracture after plate removed
Second anaesthesia for implant removalSecond anaesthesia for implant removal
Higher infection rateHigher infection rate
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ORIF Plate FixationORIF Plate Fixation
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Percutaneous BridgePercutaneous BridgePlatingPlating
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f
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Previous fracture with endostealPrevious fracture with endostealcallus- plate good optioncallus- plate good option
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External FixationExternal Fixation
AdvantagesAdvantagescan be applied rapidly,can be applied rapidly,
allows soft tissue injuryallows soft tissue injury
management ,management ,early mobilization,early mobilization,
Good option in openGood option in openfractures & poly traumafractures & poly trauma
patients patients
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External FixationExternal Fixation
DisadvantagesDisadvantages pin site sepsis, pin site sepsis,
pin site scarring, pin site scarring,
refracture,refracture,malunionmalunion
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11 yrs male RSA
Pelvic fracture, ruptured bladder
External fixation
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Ex Fix Fracture at Prox PinEx Fix Fracture at Prox Pin
Keep pin diameter
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Ex Fix RefractureEx Fix Refracture
6 months post injury
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External Fixator TipsExternal Fixator Tips
Appropriate size half pin diameter Appropriate size half pin diameter
Proper pin placement relative to fracture for Proper pin placement relative to fracture for biomechanical rigidity biomechanical rigidity
Do not remove ex fix until see bridgingDo not remove ex fix until see bridgingcorticescortices
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Medium Multi-Pin Clamp
Clamp is parallelto boneSchanzscrew is
perpendicular to bone
2cm
2cm
2cm
2cm
O F F tO F F t
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Open Femur FractureOpen Femur FracturePrinciplesPrinciples
IV antibiotics, tetanusIV antibiotics, tetanus prophylaxis prophylaxisemergent irrigation &emergent irrigation &debridementdebridementskeletal stabilizationskeletal stabilizationExternal fixation bestExternal fixation bestoption with severe softoption with severe soft
tissue injurytissue injurysoft tissue coveragesoft tissue coverage
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Open FracturesOpen Fractures
Can use temporary shunting torestore distal perfusion duringdebridement
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Trochanteric Nail TechniqueTrochanteric Nail Technique
Stay out of piriformis fossaStay out of piriformis fossa
Some use large incision/open approachSome use large incision/open approach
Over ream/small nail - starting hole and canalOver ream/small nail - starting hole and canalnonlinear nonlinear
Large diameter nail ? benefit (no reportedLarge diameter nail ? benefit (no reportednail fractures, nonunion rare)nail fractures, nonunion rare)
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Piriformis Fossa Entry SitePiriformis Fossa Entry Site
Raney E. JPO, 1993.
Thometz J, JBJS 1995.
Astion D, JBJS 1995
A t Bl d S l P i lAnatom Blood S ppl Pro imal
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Anatomy- Blood Supply ProximalAnatomy- Blood Supply ProximalFemoral EpiphysisFemoral Epiphysis
Predominantly ascendingPredominantly ascendingcervical branch (B) of cervical branch (B) of medial circumflex femoralmedial circumflex femoralarteryarteryPhysis (D) - a barrier toPhysis (D) - a barrier tointraosseous blood supplyintraosseous blood supply
from femoral neck from femoral neck
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Ganz, et al
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12 year old male, 6 mos12 year old male, 6 mos
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Small diameter solid nail, unreamedSmall diameter solid nail, unreamed
Trochanteric entryTrochanteric entry
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Trochanteric entryTrochanteric entryProximal and distal interlockingProximal and distal interlocking
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Leave some bone medial to nailLeave some bone medial to nail
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Nail removalNail removal
Some controversySome controversyCommonlyCommonlyrecommendedrecommended
Survey studies removeSurvey studies removeIM devices in childrenIM devices in childrenOutpatient procedureOutpatient procedureGrasping pliersGrasping pliers
No sports for 4 weeks No sports for 4 weeksReturn for x-rayReturn for x-ray4 weeks post removal4 weeks post removal
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SummarySummary
< 5 years early spica cast, changed technique< 5 years early spica cast, changed technique5-11 years, < 100 lbs TEN5-11 years, < 100 lbs TEN> 11, > 100 lbs trochanteric entry nail or > 11, > 100 lbs trochanteric entry nail or
bridge plating bridge platingVery distal or very proximal fracture, closedVery distal or very proximal fracture, closedIM canal, or severe axial instability bridgeIM canal, or severe axial instability bridge
plating platingSevere soft tissue injury- external fixationSevere soft tissue injury- external fixation
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