Pediatric Extra-Articular Proximal Femoral Fracture Fixation With a Submuscular Non-Locking Plate

Submuscular plating with use of a non-locking plate is indicated for the treatment of extra-articular proximal femoral fractures in children ≥6 up to 14 years old. There is no specific weight limit for the use of this procedure. The aim of the procedure is fracture stabilization and facilitation of fracture union through the use of a minimally invasive approach¹.

The surgical technique is performed with the patient under general anesthesia and in the supine position on a fracture table. A stainless steel non-locking dynamic compression plate (4.5-mm system) is placed on the anterior aspect of the thigh and examined with use of a C-arm to confirm that the chosen length is appropriate, then placed along the lateral aspect of the thigh under C-arm visualization to determine the site for proximal contouring. Proximal plate contouring is performed with use of a plate bender. Through a distal incision, a submuscular tunnel is made. A proximal incision is then made over the greater trochanter. The plate is slid from the distal to the proximal end. The plate is temporarily stabilized with use of Kirschner wires via the proximal and distal holes. After confirming the plate position with use of the C-arm, non-locking screws are placed first on the distal and then on the proximal end of the plate. A total of 3 screws are inserted into each of the distal and proximal fragments¹. Length, rotation, and alignment are confirmed postoperatively on clinical evaluation and radiographs. The patient is kept non-weight-bearing until early signs of healing are seen on radiographs, then active hip and knee range-of-motion exercises are started. Follow-up visits are conducted at 2, 4, 8, and 12 weeks postoperatively. Toe-touch weight-bearing is allowed at 8 weeks after signs of callus on radiographs. Progression to full weight-bearing is allowed on observation of radiographic fracture union. At 10 weeks, the patient is expected to be full weight-bearing. Implant removal is offered at 1 year postoperatively.

Alternatives for treating pediatric extra-articular proximal femoral fractures include the use of titanium elastic nails, rigid intramedullary nails, locking plates, limited-contact dynamic compression plates, and external fixators^2-11.

Extra-articular proximal femoral fractures by definition include fractures of the subtrochanteric region^2,3. These fractures are challenging to treat because of the strong muscular deforming forces on the proximal femur. These fractures can be length-unstable.

The results of this technique in 15 patients have been published¹. All fractures healed uneventfully, with a mean time to union of 11.8 ± 1.2 weeks. No patients required a subsequent surgery for complications or malunion. Thirteen patients achieved excellent outcomes according to the Flynn criteria.

It is important to achieve length and coronal and rotational alignment, and use the correct plate size and place it appropriately.Avoid excessive bending of the plate as it may produce varus or valgus malalignment.Choose the correct length of the plate in order to achieve stable fixation.Do not open the fracture site, as it preserves the hematoma and provides biological fixation. It is critical to stay extraperiosteal and to place the plate on the lateral surface of the femur.Keep the patient non-weight-bearing until early callus is radiographically visible. Premature weight-bearing should be avoided.

EPFF = extra-articular proximal femoral fractureDCP = dynamic compression plateAP = anteroposteriorK-wire = Kirschner wireORIF = open reduction and internal fixation.