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Review Question - QID 210215

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QID 210215 (Type "210215" in App Search)
A 1-year-old girl is a restrained passenger in a low speed motor vehicle collision and presents with left leg pain. The patient weighs 25 pounds with an isolated closed deformity of the left thigh with mild swelling. Figures A and B are radiographs obtained in the emergency department. Work up reveals no other injuries, including abdominal trauma, and child services determines there is no concern for non-accidental trauma. Which of the following would be the most appropriate definitive treatment for her injured extremity?
  • A
  • B

Application of Pavlik harness

4%

91/2270

Application of long leg splint

1%

29/2270

Flexible intramedullary nailing

3%

71/2270

Application of hip spica cast

91%

2060/2270

Application of external fixator

0%

3/2270

  • A
  • B

Select Answer to see Preferred Response

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Diaphyseal femur fractures in patients less than 6 years of age with <2cm of shortening can be treated with early spica casting.

Pediatric femoral shaft fractures are treated based on a variety of factors including age, patient weight, fracture pattern, and fracture location. Children between 6 months and 5 years of age are commonly treated with spica casting in fracture patterns with shortening <2cm. Excellent outcomes with casting in these fractures are owed to the remodeling potential of young children with significant growth remaining. The average overgrowth at union between 2 and 10 years of age is 0.9cm. Once placed in the spica the patient should be seen approximately 7-10 days later to assess for loss of reduction.

Infante et al. reviewed 175 patients at an average of 2 years follow up following immediate closed reduction and spica casting for pediatric femoral shaft fractures. They found all fractures united within 8 weeks with one refracture after a child fell one week after having his cast removed. They concluded that immediate spica casting for isolated closed femoral shaft fractures in patients under 80 pounds from birth to 10 years of age is a safe and effective treatment.

Mansour et al. compared application of spica casts in the emergency department versus in the operating room in 100 isolated closed pediatric femoral shaft fracture treated with spica cast application in the ER or operating room. They found no difference with regard to reduction, wedging of cast, or skin breakdown but did find that time to casting, hospital length of stay, and hospital charges were higher in the operating room group. They concluded that the application of a hip spica cast in the ER and OR provided similar outcomes with higher costs associated with casting in the OR.

Epps et al. evaluated results of single leg spica casting for femur fractures. They found 2 children failed due to shortening, 2 children required repeat reductions for unacceptable alignment, and there was one rotational malunion. They concluded in young children a single leg spica can safely and effectively manage simple femoral shaft fractures.

Figures A and B show an AP and lateral, respectively, of a skeletally immature patient with a transverse femoral shaft fracture. Illustration A is a 6 month follow-up of the patient showing complete healing of the fracture.

Incorrect Answers:
Answer 1: Application of a Pavlik harness is more appropriate in children with a femoral shaft fracture under 6 months of age.
Answer 2: Application of a long leg splint is not appropriate for the definitive management of a pediatric femoral shaft fracture.
Answer 3: Flexible intramedullary nailing would be appropriate for a length stable fracture in children between 5-11 years of age.
Answer 5: Application of an external fixator would be unnecessary in this scenario and indicated in the setting of polytrauma or concern for soft tissue injury.

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