Femur Fractures in Children

What are the treatments for a broken femur in children?

As in an adult, the treatment goals for a child with a broken femur include achieving proper realignment of the bone, promoting rapid healing, and returning the patient to normal activities. However, there are also unique factors and considerations in the treatment of broken bones in children. These factors include:

• The configuration of the fracture. The most common patterns are:
• Transverse fracture (straight across the shaft of the bone).
• Oblique fracture (a fracture across the bone at an angle).
• Spiral fracture (a longer fracture that usually spans a longer segment of the bone).
• The "energy" of the injury.
• The amount of soft tissue injury present.
• The patient’s size and age.
• The amount of growth the child has remaining.
• The potential for any shortening of the bone that can sometimes occur with a fracture of a growing bone.
   

How are femoral fractures in newborns and infants treated?

Femur fractures in newborns are unusual. However, they may occur, for example, in babies born with a skeletal dysplasia such as osteogenesis imperfecta − also known as brittle bone disease − or sometimes following a difficult delivery. Fractures in these children and in infants are usually treated by placing the child in a Pavlik harness, a cloth brace that helps hold the thigh in the proper position during recovery while it heals.
 

How are toddlers and young children treated for fractures of the femur?

Among children ranging from toddlers up to five, femur fractures usually result from a low energy fall, and a special type of cast called a spica cast is the most common treatment. In most cases, the orthopedic surgeon realigns the fracture using fluoroscopy or X-ray imaging as a guide and immobilizes the leg in the spica cast. This procedure usually takes place in the operating room and a pediatric anesthesiologist is present to administer a sedative or general anesthesia to keep the child comfortable.

While casting techniques vary among orthopedic surgeons, for femur fractures, the spica cast usually extends from mid-chest down the length of the affected leg and halfway down the other leg.

Children remain in the spica cast for a period ranging from four to eight weeks, but sometimes as long as three months, which can be challenge for caregivers when it comes to maintaining hygiene and keeping the child distracted and happy. Though cumbersome, spica casting continues to be the continues to be the safest and least complicated method for treating fractures among this age group and yields excellent results.

Following treatment, the orthopedic surgeon continues to monitor the patient for a period of several years to ensure that there is no limb length discrepancy.

In some patients this initial shortening, combined with the subsequent increased growth, "cancel" one another out. However, in those cases where a small limb length discrepancy occurs, the orthopedic surgeon can use a relatively simple technique, such as growth modulation of the longer leg, to address this issue.
 

Treatment for Children aged 5 to 10 years

Intramedullary nails or rods

Since the early 2000s, many pediatric orthopedists have started using intramedullary nails or rods made from strong, lightweight, and flexible titanium to stabilize femur fractures in children aged five and older. In a relatively simple technique, the orthopedic surgeon makes two small incisions − about one inch in length − on either side of the knee. After the bone is realigned, the nails are inserted up through the center of the bone where they act as an internal splint during healing.

Intramedullary nails come in a range of diameters to accommodate the varying size of children’s bones.
 

Treatment for older children and adolescents

Intramedullary nailing can also work well in older or heavier children, typically those over age 10 and heavier than 100 pounds. However, a single, thicker and more rigid nail is used rather than the smaller flexible nails.

In these children and teenagers, the nail is inserted through the top of the femur, near the hip, at a point called the greater trochanter, and locked into place with a screw at the top and the bottom of the bone. This placement avoids interruption of blood flow to the ball of the hip joint, which can lead to disabling arthritis. These concerns are not present in adults because they have different anatomy. In order to minimize the risk of complications when using intramedullary nailing in children, the orthopedist uses different devices and techniques than they would use in adult patients.
 

Submuscular plating

Submuscular plating is another treatment option for older and larger children. In this procedure, using X-ray images for guidance, the orthopedic surgeon inserts a stainless-steel plate under the muscles of the leg and across the fracture site. Through small incisions in the skin, screws are placed through the plate and bone, above and below the fracture to hold it in place. Although this technique is minimally invasive, removal of the plate is more difficult than removal of intramedullary nails.
 

External fixation

In addition to the approaches described, the fallback treatment for a femur fracture in a child of any age is external fixation.

This technique involves the use of rigid metal rods or circular rings and pins inserted into the bone to maintain alignment during healing.