Fig. 1 Radiograph of a 5-year-old boy with a proximal third femoral shaft fracture taken 10 days after reduction and spica casting (A), and at time of cast removal, 6 weeks after injury (B). The child’s injured femur was 1 cm shorter; this amount of shortening typically corrects with overgrowth in the first year after injury. Reproduced from Flynn, JM: Pediatric fractures of the femur, in Abel MF (ed): Orthopaedic Knowledge Update Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 272.


Published 8/1/2009
Ernest L. Sink, MD

AAOS releases first pediatric clinical practice guidelines

Recommendations focus on treating pediatric diaphyseal femur fractures

Pediatric diaphyseal femur fractures account for 1.4 percent to 1.7 percent of all pediatric fractures. Of every 100,000 children who sustain a fracture annually, approximately 19 will have femoral shaft fractures.

Many different options for treating femoral shaft fractures exist, and treatment is dictated by patient age, fracture characteristics, and the social situation. In the last decade, the trend has been toward surgical stabilization and away from historic nonsurgical methods such as traction and prolonged spica casting (Fig. 1).

Even within surgical stabilization, the surgeon has many different options, including the use of elastic nails, rigid nails, or minimally invasive plating. Although a large volume of literature on the surgical treatment of pediatric femur fractures exists, the answers to the following questions are not easily found:

  • What are the advantages of surgical stabilization versus traction and casting?
  • Is one surgical method more effective than another?
  • Which treatments have the best evidence supporting their use?
  • Where can orthopaedic surgeons go to review the evidence and apply it to their clinical decision making?

To answer these and other questions, the AAOS has begun developing evidence-based clinical practice guidelines (CPGs). The purpose of any CPG is to assist the practitioner and help improve patient treatment by applying the current best evidence in making clinical decisions.

The newest CPG focuses on the treatment of children and specifically addresses the treatment of isolated diaphyseal femur fractures in children who have not yet reached skeletal maturity. It is intended for use by orthopaedic surgeons and other qualified practitioners who treat pediatric patients.

Addressing the cause
The primary cause of diaphyseal femur fracture in children varies by age groups but includes falls, motor-vehicle accidents, and sports injuries. Boys have a higher risk of fracture than girls, which is consistent with participation of boys in sporting activities.

In addition, according to the Cincinnati Children’s Hospital Medical Center, “In children younger than 1 year of age, child abuse is the leading cause of femoral fractures and abuse remains a significant concern in toddlers up to about 5 years of age.”

The risk of abuse was analyzed with all available evidence, and the work group considered the importance of this possibility. As a result, the recommendation for careful evaluation for child abuse in children younger than 36 months who present with a diaphyseal femur fracture is the first of the 14 recommendations in this CPG.

The guideline also covers a wide range of treatment options, enabling physicians and patients to tailor a treatment program that meets the patient’s specific circumstances.

Fourteen recommendations
The CPG on pediatric diaphyseal femur fractures includes specific recommendations in the following four age groups: infants, children 6 months to 5 years old, children 5 to 11 years old, and children 11 years old to skeletal maturity.

The recommendations address treatment options such as the Pavlik harness, spica casts, flexible intramedullary nailing, rigid trochanteric entry nailing, and submuscular plating; they also cover pain management.

Each recommendation is graded based on the total body of evidence available to recommend for or against the intervention (Table 1). The two recommendations graded A or B are supported by good evidence (consistent Level II studies). The six grade C recommendations are supported by poor evidence (Level IV studies). Six other recommendations were graded as “Inconclusive” because evidence was insufficient or conflicting.

The following are among the recommendations with enough evidence to support a grade of recommendation:

  • We recommend that children younger than 36 months with a diaphyseal femur fracture be evaluated for child abuse. (A)
  • Treatment with a Pavlik harness or a spica cast are options for infants 6 months and younger with a diaphyseal femur fracture. (C)
  • We suggest early spica casting or traction with delayed spica casting for children age 6 months to 5 years with a diaphyseal femur fracture with less than 2 cm of shortening. (B)
  • It is an option for physicians to use flexible intramedullary nailing to treat children age 5 to 11 years diagnosed with diaphyseal femur fractures. (C)
  • Rigid trochanteric entry nailing, submuscular plating, and flexible intramedullary nailing are treatment options for children age 11 years to skeletal maturity diagnosed with diaphyseal femur fractures, but piriformis or near piriformis entry rigid nailing are not treatment options. (C)

A call for research
After using evidence-based criteria to develop the guideline, the work group concluded that the quality of the scientific data on the management of femur fractures can be improved. As long as high quality evidence to develop and support high quality recommendations is lacking, controversy on how to provide optimal treatment to our children will continue.

The members of the work group hope that future high quality research will be conducted and used to improve the CPG. The guideline includes a section on “Future Research,” which outlines the following significant areas in the treatment of children with a diaphyseal femur fracture that require additional high quality research:

“Properly designed randomized clinical trials comparing treatment options should be conducted to determine optimal treatment. These trials should ideally be multicenter trials.

“Trials investigating the following would be most helpful:

  • Delayed spica casting versus immediate spica casting for femur fractures in children 6 months to 6 years old.
  • Flexible intramedullary nailing versus immediate spica casting for femur fractures in children 5 and 6 years old, and even children younger than 5 to 6 years of age.
  • External fixation versus bridge plating versus elastic nails versus rigid trochanteric nails for length unstable femur fractures in children 6 years old to skeletal maturity.
  • Flexible intramedullary nailing versus rigid intramedullary nailing versus bridge plating for femur fractures in children 6 years old to skeletal maturity.

“Intermediate outcome measures such as radiographic parameters are often used in studies regarding pediatric femur fractures. Functional outcome measures and later development of osteoarthritis are difficult to measure and have a long time course. However, the relationship between commonly accepted radiographic measures of malunion and functional outcome or later development of problems is not clear. Further research to validate accepted radiographic standards of malunion would be extremely valuable. Also the inclusion of family function outcomes may improve recommendations for those younger patients that may either get intramedullary nailing versus immediate spica casting.”

A summary of the recommendations can be found on the AAOS Web site. The work group strongly recommends that practitioners not rely solely on the summary, but that they consult the full guideline and evidence report as well. Treatment decisions for an individual patient depend on all of the circumstances presented by that patient and mutual communication between the patient and the treating practitioner.

Ernest L. Sink, MD, served as vice chair of the work group that developed the Clinical Practice Guideline on the Treatment of Pediatric Diaphyseal Femur Fractures. He reports the following disclosure: Biomet. He can be reached at

How the guidelines came to be
The Clinical Practice Guideline on the Treatment of Pediatric Diaphyseal Femur Fractures, adopted by the AAOS Board of Directors at their June 2009 meeting, was developed by a multidisciplinary volunteer work group that included pediatric orthopaedic surgeons who practice in a variety of settings, along with assistance from the AAOS guidelines unit. They included Mininder S. Kocher, MD, MPH, chair; Ernest L. Sink, MD, cochair; R. Dale Blasier, MD; Scott J. Luhmann, MD; Charles T. Mehlman, DO, MPH; David M. Scher, MD; Travis Matheney, MD; and James O. Sanders, MD.

Funding was provided solely by the AAOS.

The guideline is based on a systematic review of the current scientific and clinical information on accepted approaches to treatment and/or diagnosis. The entire process included a review panel of internal and external committees, public commentaries, and final approval by the AAOS Board of Directors.

The methods used to prepare this guideline were rigorous, employed to minimize bias and to develop a set of reliable, transparent, and accurate clinical recommendations for treating pediatric diaphyseal femur fractures. These methods are detailed in the full guideline.


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