- Femur fracture in a child before walking age is suspicious for non-accidental trauma
- Most common femur fracture type in a child is closed, transverse, and non-comminuted
- Adolescents have adult-like mechanism for femur fracture (high energy) and associated injuries are common
- Treatment varies by age, weight, and fracture pattern
Description:Femoral diaphyseal fractures account for nearly 2 percent of all bony injuries in children, and are the most common orthopedic injury requiring hospitalization.(Sahlin, 1990;McCartney, 1994;Flynn, 2004) In the past, femur fractures in all children were commonly treated with immediate spica casting or a period of traction followed by casting.(Flynn, 2001) Non-surgical treatment with spica casting remains the standard for infants and toddlers less than 5 years; however, school-age children are now more commonly undergoing surgical intervention. Surgical treatment has reduced the burden of care for families, shortened hospital stays, and decreased the early disability and disruption in the families’ lives.(Hughes, 1995; Karn, 1986; Kirby, 1981; Buechsenschuetz, 2002)
Epidemiology:Trauma is the leading cause of death and disability in children.(Waller, 1989;Haller, 1983;Peclet, 1990) When evaluated in the late 1990’s, orthopaedic trauma led to 84,000 hospital admissions annually and a cost of nearly a billion dollars.(Galano, 2005) Femur fractures were the most common reason for admission in this group. Males more commonly sustain femur fractures, as they account for greater than 70% of injuries. There is a bimodal age distribution of fractures, first in early childhood then again peaking in adolescence. Falls and motor vehicle collisions are the most common mechanisms of injury, accounting for approximately two thirds of the injuries in older children. In younger children, a fall is the most common mechanism. Fifteen percent of femur fractures in children under 2 years and up to 80% of fractures before walking age are the result of non-accidental trauma.(Loder, 2006; Beals, 1983; Blakemore, 1996; Gross, 1983) Transverse fractures may be a better predictor of nonaccidental trauma in young children as compared to spiral fractures.(Murphy, 2015)
Clinical Findings:In the setting of suspected femur fracture, it is critical that the entire child is examined as associated injuries are common. Typical physical exam findings associated with femur fracture include: deformity, thigh swelling, and pain. However, more subtle findings may be present in the small child. Hemodynamic instability and significant drop in hematocrit are rarely present in a child with an isolated femur fracture and should alert the physician to look for associated injuries.(Ciarallo, 1996; Lynch, 1996)
Imaging Studies:X-ray evaluation should include the whole femur, as associated injuries such as an ipsilateral physeal fracture about the knee or a femoral neck fracture can occur. Plain radiographs are usually sufficient for establishing the diagnosis and for preoperative planning.
ClassificationFractures are classified by pattern, location, stability, and whether the fractures are open or closed. Fracture patterns include: transverse, short oblique, spiral, and comminuted. Level of the fracture on the femur is important, as displacement of the fracture pieces is characteristic based on the muscle attachment points and the forces applied to the fractured pieces. Stability of the fracture influences treatment. Transverse fractures are considered “length-stable” and some oblique or comminuted fractures are considered “length-unstable”. Open fractures are classified by the system of Gustilo and Anderson.(Gustilo, 1976)
Treatment:Treatment of femur fractures varies by age, fracture pattern, mechanism, weight of the child, and associated injuries. No clear consensus has been reached regarding optimal treatment, despite attempts at the creation of formal guidelines.(Kocher, 2010) There are a number of trendswhich have emerged to help guide management based on the above characteristics. Femur fractures in a child under 6 months are typically well-treated in a Pavlik harness or spica cast. For children 6 months to 5 years, spica casting (with or without pre-casting traction) has been shown by multiple studies to give good results.(Rasool, 1989; Burton, 1972) In patients 5-11 years of age, femur fractures may be treated with flexible nails, submuscular or open plating, or external fixation. Children 12 years of age and older may be treated with rigid intramedullary nailing using either a trochanteric or lateral-trochanteric starting point to minimize potential injury to the blood supply of the proximal femoral epiphysis or submuscular plating. Each treatment type has risks and benefits and may be more suited to a particular fracture pattern or patient characteristic. For example, unstable fracture patterns (oblique or comminuted) may be more difficult to control with flexible intramedullary nails and may be better suited to plating or rigid nailing. See table summarizing range of treatment options; the exact ages for transition between treatment types remains controversial and is debated. (Table 1).
Table 1. Treatment options based on patient and fracture characteristics.
(Length Stable vs. Unstable*)
|< 6 mo||Any||Any||Pavlik harness
|6 mo – 5 yrs||Any||Stable and Most unstable||Spica cast
|Any||Some unstable||90/90 traction à spica cast
Flexible nails (controversial)
|5 – 11 yrs.||< 49 kg||Stable||Flexible intramedullary nailing
|Any||Unstable||Submuscular bridge plate vs. External fixation
|> 49 kg||Any||Submuscular bridge plate vs. External fixation vs. Rigid trochanteric entry nail (in older children, but controversial)|
|> 11 yrs.||< 49 kg||Stable||Rigid trochanteric entry nail vs. Flexible intramedullary nailing|
|> 49 kg||Any||Rigid trochanteric entry nail vs. submuscular plate|
|Polytrauma or open fracture||Consider external fixation|
|Severe Comminution||External fixation vs. submuscular plating (consider use of rigid trochanteric entry nail in older kids)|
Complications:Many of the complications associated with femur fracture treatment are unique to the particular treatment modalities, though there are some sequelae common to all treatment types. The most common complication is leg length discrepancy. Particularly with nonoperative treatment, shortening is common. However, overgrowth of the bone after union often “makes up” the difference and can lead to a longer extremity on the injured side. This can occur in a wide range of ages but is thought to be most common in children age 2-4 years. Angular deformity is also common with nonoperative treatment, but some degree of angular deformity would be expected to remodel with growth. Acceptable alignment by age shown below (Table 2). Operatively treated fractures carry the additional risk of surgical site infection and wound complications as well as hardware-related pain or breakage. Refracture following hardware removal is a potential problem, most notably with fractures managed with external fixation. Complications related to flexible intramedullary nailing has been extensively studied, with reported rates ranging from 10-62% (Flynn, 200; Flynn, 2002; Moroz, 2006; Heinrich, 1994; Sink, 2005; Narayanan, 2004; Mazda, 1997; Sink, 2010). Malrotation with at least 15 degrees of external torsion has been noted in nearly 50% of patients after flexible nailing, irrespective of fracture pattern. (Salem, 2010) Case reports of femoral head AVN and trochanteric growth arrest with the use of rigid nailing has generally limited the use of this technique to older children. However, there are no reports of AVN associated with lateral entry trochanteric rigid nailing, with complication rates of rigid nailing reported as high as 10%. (MacNeil, 2011; Miller, 2012; Keeler, 2009; Crosby, 2014) Submuscular plating was recently reported to have a complication rate of 13% (6% major, 7% minor), mostly due to plate retention, at mean 20 month follow up. (May C, 2013).
Table 2. Acceptable shortening and angulation measurements of femur fractures based on age.
|Age||Varus/Valgus (degrees)||Anterior/Posterior (degrees)||Shortening (mm)
|Birth to 2 yr.||30||30||15|
|2 – 5 yr.||15||20||20|
|6 – 10 yr.||10||15||15|
|11 yr. to maturity||5||10||10|
Peer Reviewed Video LearningView Related Videos
- Beals RK, Tufts E. Fractured femur in infancy: the role of child abuse. Journal of pediatric orthopedics. Nov 1983;3(5):583-586.
- Beaty JH KJ, ed Rockwood and Wilkins' Fractures in Children. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
- Blakemore LC, Loder RT, Hensinger RN. Role of intentional abuse in children 1 to 5 years old with isolated femoral shaft fractures. Journal of pediatric orthopedics. Sep-Oct 1996;16(5):585-588.
- Buechsenschuetz KE, Mehlman CT, Shaw KJ, Crawford AH, Immerman EB. Femoral shaft fractures in children: traction and casting versus elastic stable intramedullary nailing. The Journal of trauma. Nov 2002;53(5):914-921.
- Burton VW, Fordyce AJ. Immobilization of femoral shaft fractures in children aged 2-10 years. Injury. Aug 1972;4(1):47-53.
- Ciarallo L, Fleisher G. Femoral fractures: are children at risk for significant blood loss? Pediatric emergency care. Oct 1996;12(5):343-346.
- Crosby SN Jr, Kim EJ, Koehler DM, Rohmiller MT, Mencio GA, Green NE, Lovejoy SA, Schoenecker JG, Martus JE. Twenty-Year Experience with Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients. J Bone Joint Surg Am. 2014 Jul 2;96(13):1080-1089.
- Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. Journal of pediatric orthopedics. Jan-Feb 2001;21(1):4-8.
- Flynn JM, Luedtke L, Ganley TJ, Pill SG. Titanium elastic nails for pediatric femur fractures: lessons from the learning curve. American journal of orthopedics. Feb 2002;31(2):71-74.
- Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. The Journal of the American Academy of Orthopaedic Surgeons. Sep-Oct 2004;12(5):347-359.
- Galano GJ, Vitale MA, Kessler MW, Hyman JE, Vitale MG. The most frequent traumatic orthopaedic injuries from a national pediatric inpatient population. Journal of pediatric orthopedics. Jan-Feb 2005;25(1):39-44.
- Gross RH, Stranger M. Causative factors responsible for femoral fractures in infants and young children. Journal of pediatric orthopedics. Jul 1983;3(3):341-343.
- Haller JA, Jr. Pediatric trauma. The No. 1 killer of children. JAMA : the journal of the American Medical Association. Jan 7 1983;249(1):47.
- Heinrich SD, Drvaric DM, Darr K, MacEwen GD. The operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails: a prospective analysis. Journal of pediatric orthopedics. Jul-Aug 1994;14(4):501-507.
- Karn MA, Ragiel CA. The psychologic effects of immobilization on the pediatric orthopaedic patient (continuing education credit). Orthopaedic nursing / National Association of Orthopaedic Nurses. Nov-Dec 1986;5(6):12-17.
- Keeler KA, Dart B, Luhmann SJ, Schoenecker PL, Ortman MR, Dobbs MB, Gordon JE. Antegrade intramedullary nailing of pediatric femoral fractures using an interlocking pediatric femoral nail and a lateral trochanteric entry point. J Pediatr Orthop. 2009 Jun;29(4):345-51
- Kirby RM, Winquist RA, Hansen ST, Jr. Femoral shaft fractures in adolescents: a comparison between traction plus cast treatment and closed intramedullary nailing. Journal of pediatric orthopedics. 1981;1(2):193-197.
- Kocher MS, Sink EL, Blasier RD, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on treatment of pediatric diaphyseal femur fracture. The Journal of bone and joint surgery. American volume. Jul 21 2010;92(8):1790-1792.
- Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. The Journal of bone and joint surgery. American volume. Jun 1976;58(4):453-458.
- Hughes BF, Sponseller PD, Thompson JD. Pediatric femur fractures: effects of spica cast treatment on family and community. Journal of pediatric orthopedics. Jul-Aug 1995;15(4):457-460.
- Loder RT, O'Donnell PW, Feinberg JR. Epidemiology and mechanisms of femur fractures in children. Journal of pediatric orthopedics. Sep-Oct 2006;26(5):561-566.
- Lynch JM, Gardner MJ, Gains B. Hemodynamic significance of pediatric femur fractures. Journal of pediatric surgery. Oct 1996;31(10):1358-1361.
- MacNeil JA, Francis A, El-Hawary R.A systematic review of rigid, locked, intramedullary nail insertion sites and avascular necrosis of the femoral head in the skeletally immature. J Pediatr Orthop. 2011 Jun;31(4):377-80.
- May C YY, Nasreddine AY, Hedequist D, Hresko MT, Heyworth BE. Complications of plate fixation of femoral shaft fractures in children and adolsecents. Journal of Children's Orthopaedics. June, 2013 2013;7(3):235-243.
- Mazda K, Khairouni A, Pennecot GF, Bensahel H. Closed flexible intramedullary nailing of the femoral shaft fractures in children. Journal of pediatric orthopedics. Part B. Jul 1997;6(3):198-202.
- McCartney D, Hinton A, Heinrich SD. Operative stabilization of pediatric femur fractures. Orthop Clin North Am. Oct 1994;25(4):635-650.
- Miller DJ, Kelly DM, Spence DD, Beaty JH, Warner WC Jr, Sawyer JR. Locked intramedullary nailing in the treatment of femoral shaft fractures in children younger than 12 years of age:indications and preliminary report of outcomes.J Pediatr Orthop. 2012 Dec;32(8):777-80.
- Moroz LA, Launay F, Kocher MS, et al. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. The Journal of bone and joint surgery. British volume. Oct 2006;88(10):1361-1366.
- Murphy R, Kelly DM, Moisan A, Thompson NB, Warner WC Jr, Beaty JH, Sawyer JR. Tranverse fractures of the femoral shaft are a better predictor of nonaccidental trauma in young children than spiral fractures are. The Journal of bone and joint surgery. 97(2): 106-11, 2015.
- Narayanan UG, Hyman JE, Wainwright AM, Rang M, Alman BA. Complications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid them. Journal of pediatric orthopedics. Jul-Aug 2004;24(4):363-369.
- Peclet MH, Newman KD, Eichelberger MR, et al. Patterns of injury in children. Journal ofpediatric surgery. Jan 1990;25(1):85-90; discussion 90-81.
- Rasool MN, Govender S, Naidoo KS. Treatment of femoral shaft fractures in children by early spica casting. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde. Aug 5 1989;76(3):96-99.
- Sahlin Y. Occurrence of fractures in a defined population: a 1-year study. Injury. May 1990;21(3):158-160.
- Salem KH, Keppler P. Limb geometry after elastic stable nailing for pediatric femoral fractures. J Bone Joint Surg Am. 2010 Jun;92(6):1409-17.
- Sink EL, Gralla J, Repine M. Complications of pediatric femur fractures treated with titanium elastic nails: a comparison of fracture types. Journal of pediatric orthopedics. Sep-Oct 2005;25(5):577-580.
- Sink EL, Faro F, Polousky J, Flynn K, Gralla J. Decreased complications of pediatric femur fractures with a change in management. Journal of pediatric orthopedics. Oct-Nov 2010;30(7):633-637.
- Waller AE, Baker SP, Szocka A. Childhood injury deaths: national analysis and geographic variations. American journal of public health. Mar 1989;79(3):310-315.
Top Contributors:Collin May MD
Daniel Hedequist MD