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Pediatric Femoral Shaft Fractures: Case #1
Phelo Keller, OTC

Avaiable credit for this article: 1 CEU

A two year old boy was awaken from sleep with a complaint of pain to his left leg.  He was unable to bear weight or walk on his leg.  The child had been playing with an older cousin and was found to be irritable at bedtime.  He was taken to the emergency room, and an x-ray disclosed a fracture of the left femur.

On physical exam, the right lower and both upper extremities showed full range of motion with pain and swelling over the left femoral midshaft.  There was some mild internal rotation of the extremity.  Distally, he was unable to move his toes, but his parents had noticed normal tone movement on dorsiflexion and plantor flexion.  He had good capillary refill and sensation appeared to be intact.  X-rays of the left femur showed a spiral fracture with some mild rotation and minor shortening. The fracture involved most of the midshaft portion.

Treatment:
The parents were advised of the best type of procedure for this type of fracture.  A spica cast immobilization with frequent x-rays to check for unacceptable shortening of the fracture was recommended.  The possible risks of rotational or angular deformity, as well as shortening were discussed.

Operative Procedure In Detail:
The patient was given a general anesthesia and then transferred to the spica table. Stockinet, cast padding and felt were applied in the usual manner.  The torso portion of the cast was then applied. The C-arm image intensifier was then brought in. The fracture was reduced under C-arm image control and the extremity was held by an assistant.  Cast application proceeded for the left lower extremity.  Final C-arm images were taken as the cast was drying and showed quite adequate position of the long oblique fracture. The right leg was then incorporated into the cast and a bar fashioned between the two legs for additional support. With the cast dry, the patient was rolled supine onto his hospital bed and final posterior trimming was accomplished. He left the operating room in satisfactory condition.

Most physicians recommend treatment based on the child’s age. Younger children with isolated femoral shaft fractures are managed by a variety of closed techniques.  An older or polytraumatized child may receive more aggressive intervention. The remodeling potential of the child justifies a decision. The family or social situation of the child affects the treatment plan. Potentially abused children require admission to the hospital, whereas children with favorable family environments may be candidates for immediate casting and discharged to home. The patient’s family issues can complicate management.  A physicians experience and training also affect the treatment plan. Physicians with little experience and training may feel overwhelmed when tackling these injuries. Pediatric femoral shaft fractures require strict attention to detail and frequent meticulous follow up. Parental education regarding the injury is also time consuming. These demands may overly challenge some busy practitioners. The hospital or institution may likewise urge the transfer of the patient, especially when lack of accreditation or facilities to care for children exists. Immobilization in a spica cast with early discharge home when indicated is less expensive.  Given equivalent results, this method may be the treatment of choice when local inpatient pediatric services or family resources are lacking.

At the first follow up visit, the patient is tolerating the cast well, and x-rays look fine after a month.  Post fracture x-rays showed abundant callus with no change in position. This cast will be ready for removal in another two weeks.



Within seven weeks of healing the fracture is healed in excellent position on x-ray. His cast was removed.  Instructions to his parents included, immobilization to tolerance.  In his last visit, both leg lengths looks just about equal and showed good range of motion. Gradually he will start to bear more weight on his legs with encouragement from his parents.  The patient was released with the understanding that he should return if improvement stops.

References:
Charles A. Rockwood, “Fractures in Children”

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