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 studies^1,2 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

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.

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
 
Based on the summary of evidence, we did not find conclusive evidence that one modality of treatment (spica casting or traction) was superior and no studies compared flexible nails to spica casting in this age group. We suggest using early spica casting for social and economic considerations, specifically in relative ease of care and decreased length of hospital stay.²¹  While the work group suggests early spica for children in this age group, traction may be appropriate in some cases. This recommendation does not suggest against the use of traction. In keeping with current best medical practice, we further suggest careful clinical and radiographic follow-up during the course of treatment.
 
In addition, no trial has specifically examined children in the age group of 4-5 years. A  third study²² indicates that  in children as young as four more malunions occur with spica casting than with external fixation. Treatment decisions made on children who border any age group should be made on the basis of the individual. Until further research clarifies the possible harms associated with any treatment in this age group, decisions will always need to be predicated on guardian and physician mutual communication with discussion of available treatments and procedures applicable to the individual patient. Once the patient’s guardian has been informed of available therapies and has discussed these options with his/her child’s physician, an informed decision can be made. Clinician input based on experience increases the probability of identifying patients who will benefit from specific treatment options. 

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.

2009 RATIONALE:

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.)
 
The high quality study²² found to address this recommendation compared external fixation to spica casting. External fixation was favored over spica casting for malunions, including anterior/posterior angulation. Twelve other outcomes for this comparison had non-significant results. 
 
In summary, the overall body of evidence considered for this recommendation indicates that there are few significant outcomes when all comparisons are considered. Further, important comparisons have not been investigated (spica casting and flexible nails). 
 
Two moderate quality studies^{24, 50} shows more rapid return to walking and school with flexible intramedullary nailing and one low quality study²⁵ illustrates less associated hospital costs when compared to traction and casting. The ability to mobilize the patient, return them to school rapidly, and suggested decrease in hospital costs leads the work group to suggest flexible intramedullary nailing over traction followed by casting. There is evidence that flexible intramedullary nailing has less adverse events and more rapid return to school than external fixation in both stable and unstable fractures.²⁶
 
In making this recommendation, the work group acknowledges that they are including their expert opinion and they have therefore, downgraded the Grade of this Recommendation to a “limited” recommendation.  Based on the advantages suggested, less adverse events and more rapid return to school, flexible intramedullary nailing is a treatment option for children five to eleven years diagnosed with diaphyseal femur fractures.  
 
There is currently insufficient literature in specially designed pediatric rigid intramedullary nails and bridge plating for inclusion in the current guideline.
 
Patients over age 11 or with weight over 49 kg are at increased risk of a poor outcome²⁷ with flexible intramedullary nailing. The mean weight between patients with a poor outcome and those with an excellent or satisfactory outcome was significant, but weight was not independent of age and had a sensitivity of only 59% in predicting poor outcomes. 

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.

 

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.