Femoral shaft fractures used to be devastating injuries before invention of intramedullary nails by Kuentscher during World War 2.
Treatment with intramedullary nail makes all the difference, but is not without risks.
The operation usually is done on a fracture table. The fracture table helps secure the foot and the body, and helps perform "closed reduction" of the femur by allowing the surgeon to apply a correct amount of traction.
After closed reduction, under xray guidance, 3-5 incisions are made in order to insert the implant:
This was a closed fracture, with physes almost fully closed.
Casting is certainly not a good option for this injury.
An external fixator is an option, but not the best option. An external fixator will not hold the alignment as reliably as an intramedullary nail, and there is the issue of pin tract infetion as well.
An intramedullary nail is the correct treatment for this fracture, without any doubt. There is always a small risk of infection, anytime there is an incision through the skin. But the risk-benefit analysis is strongly in favor in intramedullary nailing.
At this age group, there is some talk in orthopedic pediatric circles of the risk of AVN with a traditional pyriformis entry nail. Because of that theoretical risk, I chose to use a Synthes lateral entry intramedullary implant.
The operation is done on a fracture table. The broken femur ends are pulled apart, are aligned by external pressure, and the intramedullary nail is inserted. Power drills and hammers are used during this surgery.
Immediate postoperative xrays
This patient was allowed to bear full weight from the beginning, with this 9 mm nail.
The fracture healed well and on time, as expected.
Limping was severe for the first month, less of a problem in the second month. By 3 months, normal gait had been restored.
Here are the xrays, showing a healed femur, at 3 months.
Issues such as removal of the nail, always come up in discussions with the parents.
As far as I know: