Femur Anatomy

Definition: Fracture of the femoral diaphysis between the area 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle

Mechanism

  • Direct Trauma: Motor vehicle collision, fall, child abuse
  • Indirect Trauma: Rotational injury
  • Pathologic Fracture: Secondary to osteogenesis imperfecta, tumors, bone cysts, non-ossifying fibromas

Epidemiology

  • Bimodal distribution: Peaks from age 2 to 4 and again in mid-adolescence
  • In children too young to walk, 80% are caused by child abuse
  • Male predominance: 2.6:1

Physical Exam

  • Inability to ambulate, extreme pain, tenderness to palpation (Eiff 2018)
  • Thigh swelling and gross deformity common but not universally present
  • Arterial Injury: distal paresthesias, diminished pulses
  • Compartment syndrome: distal paresthesias, diminished pulses, distal weakness, pain with passive range of motion

Classification

  • Descriptive (Egol 2010)
    • Skin: open vs closed
    • Level of fracture: proximal, middle, distal third
    • Fracture pattern: transverse, spiral, oblique, butterfly fragment
    • Comminution
    • Displacement
    • Angulation
  • Anatomic
    • Subtrochanteric
    • Shaft
    • Supracondylar

Femoral Shaft Fracture Classification (pathologies.lexmedicus.com)

Imaging

  • Views
    • AP and lateral femur XR
    • Ipsilateral hip and knee XR to rule out associated injuries
  • CT or MRI
    • Generally unnecessary in acute management
    • Consider to rule out associated femoral neck or acetabulum fracture
  • Consider skeletal survey and head CT in infants with suspected non accidental trauma

ED Management

  • In patients with a high energy mechanism of injury, start with a full head-to-toe trauma evaluation
  • Remove any splints or bandages placed in the field and examine the overlying soft tissue to rule out open fractures
    • Open fractures should be given antibiotics and tetanus booster
  • Perform a complete neurovascular exam
  • Pain management
    • Systemic analgesics
    • Femoral nerve blockuee
    • Immobilization with splinting and/or traction can provide significant analgesia
  • Orthopedic consult or transfer
  • Always consider non accidental trauma in young children, consult child abuse specialist and social work as needed
  • Treatment depends on age, fracture pattern, location, soft tissue trauma, and associated injuries; the American Academy of Orthopedic Surgeons summary recommendation

Age

Treatment Options

≤6 months

Pavlik harness or

Immediate spica cast

6 months – 5 years

Immediate spica cast or

Traction → spica cast

5 years – 11 years

Flexible intramedullary nailing or

Immediate spica cast

11 years – maturity

Rigid intrameddulary nailing or

Submuscular/open plating or

Flexible intramedullary nail (if <50 kg)

Prognosis

  • Children have a rapid and high rate of remodeling and few complications. As children get older their rates or remodeling decrease. .
  • Potential complications include: leg length discrepancy (shortening or overgrowth), muscle weakness, osteonecrosis, malunion, and rarely nonunion

Take Home Points

  • Do a full trauma exam on patients with femur fractures. Often, the injury occurs with a high energy mechanism and is associated with other injuries
  • Consider non accidental trauma in children under 3 with this fracture pattern
  • Provide early immobilization and orthopedic consultation

Read More:

OrthoBullets: Femoral Shaft Fractures

Up to Date: Femoral Shaft Fractures in Children

References

Anglen JO, Choi L. Treatment options in pediatric femoral shaft fractures. J Orthop Trauma. 2005; 19(10): 724-33. PMID: 16314721

Beaty JH, Kasser JR (Eds). Rockwood and Green’s Fractures in Children. Lippincott Williams & Wilkins, Philadelphia. 2010; 797 -841.

Cramer KE, Limbird TJ, Green NE. Open fractures of the diaphysis of the lower extremity in children. Treatment, results, and complications. J Bone Joint Surg Am. 1992; 74(2): 218-32. PMID: 1541616

Eiff MP, Hatch R. Femur and Pelvis Fractures: Femoral Shaft Fractures. Fracture Management for Primary Care. 3rd ed. Philadelphia: Elsevier Saunders. 2018; 221-224

Egol KA, Koval KJ, Zuckerman JD. Pediatric Femoral Shaft. Handbook of Fractures. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2010: 690-697

Flynn JM, Skaggs DL. Femoral shaft fractures. Rockwood and Wilkins’ Fractures in Children, 7th Ed.

Poolman RW, Kocher MS, Bhandari M. Pediatric femoral fractures: a systematic review of 2422 cases. J Orthop Trauma. 2006; 20(9): 648-54. PMID: 17088672

Kocher MS et al.  Treatment of pediatric diaphyseal femur fractures. J Am Acad Ortho Surg. 2009; 17(11): 718 -25. PMID: 19880682

Heyworth BE et al. Management of pediatric diaphyseal femur fractures. Curr Rev Musculosketal Med. 2012; 5(2): 120-25. 22315162

Lewiss RE, Saul T, Shah KH. Femur Shaft Fracture. Essential Emergency Imaging. Philadephia: Lippincott Williams & Wilkins; 2012: 611-613

Madhuri V et alP. Interventions for treating femoral shaft fractures in children and adolescents. Cochrane Database Sys Rev. 2014; 29(7): CD009076. PMID: 25072888