On-call orthopaedic surgeons know that when their phone rings in the middle of the night, they may need to provide emergency care for a child with a challenging injury. Jack Flynn, MD, discussed treatment of one such injury—the pediatric femur fracture—during an instructional course lecture held at the 2015 AAOS Annual Meeting.

It is crucial to engage in careful decision-making while treating young patients with femur fractures and to draw on technical “pearls” that lead to good outcomes, according to Dr. Flynn, who serves as orthopaedic trauma director and chief of orthopaedics at Children’s Hospital of Philadelphia, as well as professor of orthopaedics at the University of Pennsylvania.

Treatment options, considerations

Dr. Flynn began by noting that when a child who is not yet walking—ie, usually younger than 1 year old—has a femur fracture, orthopaedists should consider whether child abuse may be involved. If so, the treating surgeon may have legal and ethical responsibilities to report the situation and ensure the safety of the child.

That said, the following seven treatment options currently exist for pediatric femur fractures:

• Pavlik harness (with or without splint)
• Walking spica cast
• Standard spica cast (with or without traction)
• Elastic nailing
• Submuscular plating
• External fixation
• Trochanteric-entry nailing

Before choosing a treatment option, however, orthopaedists must consider a number of different factors, including the patient’s age.

“Younger children heal faster and have astounding remodeling capacity,” said Dr. Flynn, who also noted that mobility issues and the patient’s weight should be considered.

“We’re not putting 10- and 12-year-olds in spica casts anymore,” said Dr. Flynn, citing patient mobility issues. “Also, some children, due to their weight, are just too big for elastic nails.”

Fracture personality—meaning whether there is significant risk of femoral shortening—must also be taken into account. The surgeon’s skills, experience, equipment, and medical team may also factor into the decision-making process, said Dr. Flynn.

Classification and treatment
When Dr. Flynn and his family went on a whitewater rafting trip a few years ago, he noticed the classification system used to indicate the difficulty levels of whitewater rapids—Class 1, easy; Class 2, novice; Class 3, intermediate; Class 4, advanced; and Class 5, expert—can also serve as a helpful guide for classifying and treating pediatric femur fractures.

“A ‘Class 1’ femur fracture is going to heal itself,” he said. “The orthopaedist should not over treat the fracture, which will make things worse for the child and his or her caregivers.”

According to Dr. Flynn, an orthopaedist might see this type of fracture in an infant being cared for in a hospital’s neonatal intensive care unit (NICU).

“In an infant who is 4 months old or younger, we use a splint and a Pavlik harness,” Dr. Flynn said, noting that these fractures heal very quickly and that it is important to avoid a skin problem in these young patients. “The Pavlik harness will work up to about 5 to 6 months of age. After that, a regular spica cast is better.”

According to Dr. Flynn, the walking spica cast has received renewed attention in the last few years for its use in children aged 4 years or younger who have sustained a fairly low-energy femur fracture with less than 1 cm of femoral shortening.

Another “Class 1” patient, he added, might be a child with a minimally displaced insufficiency fracture who is wheelchair-bound, due to cerebral palsy.

“In that patient, you might just need to use a well-padded cast or splint,” said Dr. Flynn.

Dr. Flynn considers nonoperative fractures treated with casts to be “Class 2” fractures.

“This is a fracture that requires a lot more attention,” he said “In one scenario, this could be in a child who is younger than 4 years old, with a low-energy fracture and shortening that may be less than 2 cm. In this patient, a walking spica cast would be ideal but will likely require wedge adjustment.”

He also noted that a standard spica cast would likely be appropriate in a child younger than 5 years of age with femoral shortening of as much as 3 cm. Again, the orthopaedist would likely need to perform wedge adjustment of the cast.

“What I call ‘Class 3’ is the class that has changed the most since I started practicing in the mid-1990s, when we were using a lot of traction and casting for it,” said Dr. Flynn. An example of this fracture might be a 5-year-old patient who sustained a high-energy femur fracture with shortening of more than 3 cm.

“Around the country and the world, people have moved to using a load-sharing implant—usually, an elastic nail—for this type of fracture,” continued Dr. Flynn, noting that, depending on the child’s weight, elastic nailing may be appropriate for a child as old as 10 to 12 years with a length-stable fracture.

Dr. Flynn considers a “Class 4” fracture to be one that requires surgery and rigid fixation. Examples of patients who may fall into this category include 5- to 9-year-old children who have sustained a high-energy, comminuted fracture with unstable length. Such patients might require external fixation or submuscular plates, he said.

According to Dr. Flynn, a locked trochanteric entry nail is the best option for patients who are 9 to 14 years old, have a higher body mass index than is acceptable for elastic nailing, or have unstable length. Patients who are 14 years old or older should be treated with a locked trochanteric nail, he said.

Dr. Flynn asserted that “Class 5” patients, meaning those who are at risk of losing the limb, are limited to multitrauma patients with open fractures. Dr. Flynn noted that, to treat a younger child—such as a 5-year-old—the surgeon might opt to use external fixation first, or might begin with traction, and then move to external fixation in a staged fashion. In an older child—such as a 12-year-old—treatment might include external fixation followed by a trochanteric entry nail, when the patient is stable enough, he said.

Treatment pearls
Dr. Flynn offered tips for maximizing the benefits of the various treatment methods, starting with the Pavlik harness.

“The Pavlik harness is really a terrific method for treating infants in the NICU,” he said, “but we need to make sure family members are aware they need to handle the baby with care, because the child is going to be a bit sore and is not really immobilized.

“When applying the walking spica cast,” he continued, “orthopaedists should flex the hip and knee about 45 degrees and reinforce the hip. That is really important or else the leg part of the cast will break off as the child starts to walk at 3 to 4 weeks after injury.

“You should also make sure you put a really good valgus mold at the fracture site because patients will start drifting into varus,” he said. “In addition, orthopaedists should make sure they see the child in clinic about 10 days post-injury and should be ready to perform wedge adjustment of the cast.

“I tell the families right from the day of injury that the cast is probably going to need a ‘10,000 mile tune-up,’ and it’s probably going to happen between the first and second week after injury,” he added.

Another tip regarding the standard spica cast is to avoid putting on a short leg cast and pulling hard, to prevent leg compartment syndrome from developing.

Dr. Flynn warned against using elastic nails in obese, older children.

When using elastic nails, he said, “distally, do not bend the tip of the elastic nail away from the bone because it will result in soft tissue irritation. Proximally, get the nail tip into that dense bone in the proximal metaphysis, to create good control in terms of shortening and rotation. Expect the patient to be sore for 2 to 3 weeks. A knee immobilizer may be used for approximately 6 weeks after surgery in these patients.”

In submuscular plating, the plate “should be long and strong,” said Dr. Flynn.

“Be careful with distal contouring, because some studies have shown that submuscular plating may create deformities,” he said. “Do not use locking screws with submuscular plating, and make sure the appropriate length is achieved before beginning fixation; hold the bones in place with wires if necessary.”

According to Dr. Flynn, the external fixator still has a role, particularly in ‘damage-control’ orthopaedics.

“Sometimes I use an external fixator as portable traction, leaving it on for 8 to 10 weeks,” he said. “When I remove the fixator, I will put the child in a walking spica cast that protects both the pin holes and the fracture as it finishes healing. The iliotibial band can be released to make knee motion possible while the fixator is on.

“External fixation is not something we do very often but it is nice to have in your arsenal,” he added.

Dr. Flynn’s final advice related to trochanteric entry nailing, treatment reserved for older pediatric patients.

“We generally use the smallest diameter nail that we think will get the job done when doing trochanteric entry nailing,” he said. “We enter the trochanter far lateral—never from the tip, which would put the blood supply at risk. We perform minimal reaming at the entry site, and then we lock it just as we would if we were treating an adult.”

Dr. Flynn served as moderator of “The Kids You See on Call: Pearls for Managing Urgent Pediatric Orthopaedics.” Other presenters included James H. Beaty, MD; Martin J. Herman, MD; and David L. Skaggs, MD.

The authors’ disclosure information, including potential conflicts of interest, can be viewed at www.aaos.org/disclosure

Jennie McKee is a senior science writer for AAOS Now. She can be reached at mckee@aaos.org

Bottom Line

• Child abuse may be a factor in femur fractures in children younger than 1 year of age.
• Depending on the patient’s age and the type of fracture, treatment options include a Pavlik harness (with or without splint), a walking spica cast, a standard spica cast (with or without traction), elastic nailing, submuscular plating, external fixation, or trochanteric-entry nailing.
• The walking spica cast may be used in children aged 4 years or younger who have sustained a fairly low-energy femur fracture with less than 1 cm of shortening.
• Walking spica casts should be adjusted about 10 days post-injury to avoid a drift into varus.
• External fixators have a role, particularly in ‘damage control’ orthopaedics.

Additional Information:
Child Abuse or Maltreatment, Elder Maltreatment, and Intimate Partner Violence (IPV):  The Orthopaedic Surgeon’s Responsibilities in Domestic and Family Violence