|Treatment of Pediatric Diaphyseal Femur Fractures|
Strong evidence supports that children younger than thirty-six months with a diaphyseal femur fracture be evaluated for child abuse.
Our systematic review identified three high quality population-based studies that identified femur fractures in children caused by child abuse from three different registries. Two of these studies1,2 reported 14% and 12% of the fractures were the result of abuse in children zero to one year old and zero to three years old, respectively. The third study reported that only two (2%) of the fractures were caused by abuse among children zero to 15 years old, which would correspond to 13% if both of these fractures occurred in children zero to one year old.
The work group recognizes that the most important elements in evaluating a child for abuse are a complete history and physical exam with attention to the signs and symptoms of child abuse. The work group defines “evaluating” a child for abuse however, as not only these routine elements, but also including direct communication with the patient’s pediatrician or family doctor, consultation with the child abuse team at institutions where this may be available, and selective ordering of a skeletal survey by the orthopaedist when considered appropriate by the treating physician. In cases of possible child abuse, these professionals can add valuable input, based on experience, which increases the probability of identifying patients who may be at increased risk.15
In addition, the work group emphasizes that children who are not yet walking and sustain a femur fracture are at particular risk for abuse7, so one must make every attempt to identify these patients. One of the studies2 reports 48 of 49 child abuse-related femur fractures occurred in the less than three year old age group. This author found that in 332 femur fractures in children 0-3 years of age forty-eight of them were due to abuse. Accordingly, there were 451 children, four to twelve years of age, who had femur fractures and only one child in this age group was confirmed as abused. There were no cases of child abuse identified in the thirteen to seventeen year old age group. The work group acknowledges that this study is not exclusively reporting data on shaft fractures and has isolated the data specific to shaft fracture in the following data tables. However, the study does illustrate the need to focus on the patients who are less than three years old.
Estimates of child abuse suggest that the incidence is underreported and the consequences of missing it result in serious complications including death.2
Infant Femur Fracture
Limited evidence supports treatment with a Pavlik harness or a spica cast for infants six months and younger with a diaphyseal femur fracture, because their outcomes are similar.
The first 6 months of a child’s life is a time of most rapid growth. Because of this, rapid healing of diaphyseal femur fractures and post-fracture skeletal remodeling is maximal. Hence spontaneous, complete correction after fracture healing is expected. Due the rapid union and complete remodeling, treatment of diaphyseal femur fractures centers on assuring ease of patient care and minimizing treatment complications. Both Pavlik harnesses and spica casts result in good outcomes with minimal complications. In the studies we reviewed, the only identifiable difference between these two treatments was more frequent skin complications in the spica cast group. Because this is a minor and correctable issue that does not cause long-term problems or disability, either type of treatment is an option.
Early or Delayed Spica Casting
Moderate evidence supports early spica casting or traction with delayed spica casting for children age six months to five years with a diaphyseal femur fracture with less than 2 cm of shortening.
Two studies compared the use of early spica casting with traction followed by spica casting. There were significantly more infections in the traction group and more spica softening and plaster breakage in the early spica group.19 There were no statistically significant differences between the treatment groups in time to union, femoral shortening, malalignment, or malrotation.19,20
Elastic Intramedullary Nails
Strong evidence supports the option for physicians to use flexible intramedullary nailing to treat children age five to eleven years diagnosed with diaphyseal femur fractures.
There are few statistically significant differences between treatments in healing of the fracture. The evidence reviewed included ten studies that examined one hundred varying outcomes. Of these one hundred outcomes twenty-one were significant. There were no studies that directly compared flexible nails to spica casting. When flexible nails were compared to external fixation and traction plus casting, nine outcomes were significant favoring flexible nails, one significant outcome favored external fixation and one significant outcome favored traction plus casting. (Please refer to Tables 6 and 7 below.)
Previously Published Systematic Reviews:
Two previous systematic reviews21,23 concluded that early spica casting was associated with shorter inpatient hospital stays and fewer adverse events than traction. One review23 concluded that flexible nails reduced the malunion and adverse event rate compared to external fixation, and that external fixation reduced the malunion rate compared to early spica casting. This review also concluded that dynamic external fixation had a lower total adverse event rate compared to static external fixation, and that operative treatment reduced the malunion and total adverse event rates compared to nonoperative treatment. Both of these reviews, however, were not specific to the population of interest for this recommendation, so we did not include them in our systematic review.
2020 Update Supporting Evidence: Ahmad, I, Gilani, H. U. R, Rasool, K, Rasool A. Comparison of titanium elastic nailing vs hip spica cast in treatment of femoral shaft fractures in children between 6-12 years of age. Pakistan Journal of Medical and Health Sciences. 2015 January;9(2): 717-719.
Naseem, M, Moton, R. Z, Siddiqui, M. A. Comparison of titanium elastic nails versus Thomas splint traction for treatment of pediatric femur shaft fracture. J Pak Med Assoc. 2015 Nov;65(11 Suppl 3):S160-2.
Soleimanpour, J, Ganjpour, J, Rouhani, S, Goldust, M. Comparison of titanium elastic nails with traction and spica cast in treatment of children's femoral shaft fractures. Pak J Biol Sci. 2013 Apr 15;16(8):391-5.
ORIF Pediatric Femur Fractures
Limited evidence supports rigid trochanteric entry nailing, submuscular plating, and flexible intramedullary nailing as treatment options for children age eleven years to skeletal maturity diagnosed with diaphyseal femur fractures, but piriformis or near piriformis entry rigid nailing are not treatment options.
Skeletally immature patients are at increased risk for avascular necrosis of the femoral head when piriformis or near piriformis fossa entry nails are used. The rate of this potentially devastating complication is at least 4%.38 Every effort should be made to decrease the risk of avascular necrosis.
Fracture patterns that compromise post-reduction stability (i.e. axial and / or angular stability) as well as heavier patients may stimulate the surgeon to choose rigid trochanteric entry nailing or submuscular plating over flexible intramedullary nailing. One Low quality study demonstrated a five times higher risk of poor outcomes for flexible nailing in patients whose weight met or exceeded 49 kg (108 lbs).27 In the expert opinion of the work group, external fixation is another option in the older patient with an unstable fracture pattern, but its significantly higher complication rates, as demonstrated in other age groups,23,26 make it less desirable than rigid trochanteric entry nailing or submuscular plating.
Limited evidence supports regional pain management for patient comfort peri-operatively.
We identified one High quality study45 of a hematoma block and one Low quality study46 of a femoral nerve block, both of which were effective at reducing pain. In the expert opinion of the work group, the risks associated with regional pain management, such as femoral nerve neuritis and the complications associated with epidural anesthesia in lower extremity fractures (missed compartment syndrome), are less than with oral or IV systemic medicines.
Limited evidence supports waterproof cast liners for spica casts are an option for use in children diagnosed with pediatric diaphyseal femur fractures.
Waterproof cast liners are often used when applying a spica cast for the management of femur fractures in children in order to improve ease of care.
We identified one High Quality study48 that addressed the use of waterproof liners in spica casts. Use of a waterproof liner was associated with significantly fewer skin problems and unexpected cast changes. However, in this study spica casts were used for the management of developmental dysplasia of the hip, not specifically for diaphyseal femur fractures. In addition, other outcomes such as impact on family and financial considerations were not studied. Waterproof liners may make cast care easier for the family, thus decreasing the overall impact of treatment on family functioning. Cast liners add increased cost to overall management. Nevertheless, the patient ages were similar to the patient ages for spica cast management of diaphyseal femur fractures and the findings should be able to be extrapolated. The overall benefit in terms of skin problems, unplanned cast changes, and ease of care for the family likely obviates the increased costs from the use of waterproof cast liners in the expert opinion of the physician work group.
2020 Development Group Roster:
- AAOS Committee on Evidence-Based Quality and Value
- Karl C. Roberts, MD, FAAOS
- Benjamin J. Miller, MD. FAAOS
- Henry Bone-Ellis, Jr., MD, FAAOS
- Selina Poon, MD, FAAOS
- Laura Lowe Tosi, MD, FAAOS
2020 AAOS Staff:
- Danielle Schulte, MS, Manager, Clinical Quality and Value
- Tyler Verity, Medical Research Librarian, Clinical Quality and Value
- Kaitlyn Sevarino, MBA, CAE, Director, Clinical Quality and Value
2015 Guideline Update Work Group:
- David S. Jevsevar, MD, MBA, Chair, AAOS Evidence-Based Quality and Value Committee
- Kevin Shea, MD, Guidelines Oversight Leader, Evidence-Based Quality and Value Committee
2015 AAOS Staff:
- William Shaffer, MD, AAOS Medical Director
- Deborah Cummins, PhD, Director, Department of Research and Scientific Affairs
- Jayson Murray, MA, Manager, Evidence-Based Medicine Unit
- Ben Brenton, MPH, Research Analyst, Evidence-Based Medicine Unit
- Anne Woznica, AAOS Medical Librarian
- Kaitlyn Sevarino, Evidence-Based Quality and Value (EBQV) Coordinator
- Erica Linskey, Administrative Assistant, Evidence-Based Medicine Unit
2007 Guideline Work Group:
- Mininder S. Kocher, MD, MPH, Chair
- Ernest L. Sink, MD, Co-Chair
- R. Dale Blasier, MD
- Scott J. Luhmann, MD
- Charles T. Mehlman, DO, MPH
- David M. Scher, MD
- Travis Matheney, MD
- James O. Sanders, MD
2007 Guidelines Oversight Committee:
- William C. Watters III, MD, Chair
- Michael J. Goldberg, MD, Vice Chair
2007 AAOS Evidence Based Practice Committee:
- Michael Warren Keith, MD, Chair
2007 AAOS Staff:
- Robert H. Haralson III, MD, MBA, AAOS Medical Director
- Charles M. Turkelson, PhD, Director of Research and Scientific Affairs
- Janet L. Wies, MPH, Manager, Clinical Practice Guidelines
- Patrick Sluka, MPH, Lead Research Analyst
- Rich McGowan, MLS, AAOS Medical Librarian