Pediatric Femoral Shaft Fracture: An Age-Based Treatment Algorithm

Abstract

Purpose: Fractures of the femoral shaft in children are common. The rates of bone growth and remodeling in children vary according to their ages, which affect their respective management.

Methods: This paper evaluates the incidence and patterns of pediatric femoral shaft fracture and the current concepts of treatments available.

Results: The type of fracture-closed or open; stable or unstable-needs to be taken into account. Child abuse should be suspected in fractures sustained by infants. For younger children, non-surgical management is preferred, which include Pavlik harness (< 6 months old) and early spica casting (6 months to 6 years old). Older children (> 6 years old) usually benefit from surgical treatments as outcomes of non-surgical alternatives are worse and are associated with prolonged recovery times. These operative measures for older children that are 6-12 years old include elastic stable intramedullary nailing and submuscular plating. Factors to be considered when devising an appropriate intervention include body mass, location of injury, and nature of fracture. For adolescent and skeletally mature teenagers (> 12 years old), rigid antegrade entry intramedullary fixation is indicated. In the event of open fractures or polytrauma, external fixation should be considered as a temporary treatment method for initial fracture stabilization.

Conclusion: An age-based and evidence-based algorithm has been proposed to guide surgeons in the process of evaluating an appropriate treatment.

Keywords: Adolescents; Algorithm; Children; Evidence; Femur; Fracture; Management; Pediatric; Review; Shaft.

Fig. 1

Algorithm of treatment for femoral shaft fractures in children

Fig. 2

Classification of bone segments (left) and bone types (right) of the femur

Fig. 3

Classification of long bone fractures in children

Fig. 4

a X-ray of a right proximal 1/3 closed spiral femoral diaphyseal fracture in a boy aged 6 years, sustained from a road traffic accident. b X-ray of a right middle 1/3 closed transverse femoral diaphyseal fracture, supported by external fixators. c X-ray of a right proximal 1/3 closed comminuted femoral diaphyseal fracture in a boy aged 15 years, sustained from a road traffic accident

Fig. 5

a–c Pre-operative X-ray of a 6-year-old boy (18 kg) with a left middle 1/3 closed spiral femoral diaphyseal fracture, sustained from a fall. d, e Post-operative X-ray taken at 9 months, showing good three-point fixation by TEN with end caps for fracture stabilization and abundant callus formation

Fig. 6

a Immediate post-operative X-ray of an 11-year-old (35 kg) boy with a right middle 1/3 closed comminuted femoral diaphyseal fracture treated with TEN and stabilized with end cap. b Post-operative X-ray taken at 6-months, showing satisfactory recovery in terms of length, angulation, and rotation

Fig. 7

X-ray of a 10-year-old boy (50 kg) with a left middle 1/3 closed comminuted femoral diaphyseal fracture treated with submuscular bridging plate. Due to unstable nature of fracture and heavy weight of patient, plating is more beneficial as a treatment

Fig. 8

X-ray of a 9-year-old boy (40 kg) with a left proximal 1/3 closed comminuted femoral diaphyseal fracture along with long spiral fractures and intra-abdominal injury treated with external fixation (mainly for unstable patients and unstable fractures)

Fig. 9

a Immediate post-operative X-ray of a 15-year-old boy (50 kg) with a right proximal 1/3 closed comminuted femoral diaphyseal fracture treated with lateral trochanteric entry rigid intramedullary nailing. b Post-operative X-ray taken at 4 months, showing good union and recovery