Review Question - QID 214155

For a 7-year-old patient with a length stable femur shaft fracture, the best treatment is closed reduction and flexible nailing.

Femoral shaft fracture treatment in pediatric patients varies based upon age, weight, and fracture characteristics. In a patient between 5 and 11 years of age, who weighs less than 49kg, and has a length-stable fracture, flexible intramedullary nails are a reasonable treatment option. Patient weight > 49 kg is associated with a greater risk of construct failure and malunion. Patients less than 5 years can be treated in a spica cast. Length unstable fractures (comminution or fracture length > 2x bone diameter) in 5-11 year olds require submuscular bridge plating or stainless steel Ender's nails. Older patients where physeal injury is less of a concern and have sufficient size medullary canals can also be treated with rigid intramedullary nail fixation, similar to adults.

Kocher et al. published fourteen American Academy of Orthopedic Surgeons Clinical Practice Guidelines for the treatment of pediatric femur fractures in JAAOS (an in-depth, descriptive version; reference 1), and in JBJS (a concise version; reference 2). A summary of their recommendations are:
1. patients less than 36 months of age, should be evaluated for child abuse (strong recommendation)
2. Patients between 6 months and 5 years should be treated in a spica cast. They do not recommend for or against weight, angulation, or shortened fractures to be treated in a spica cast (moderate recommendation)
3. Patients less than 6 months should be treated in a Pavlik harness
4. Patients 5 to 11 years can be treated with flexible intramedullary nails
5. Patients 11 to maturity can be treated with rigid intramedullary nails
6. They do not recommend for or against the use of physical therapy or the use of locked or nonlocking plates.

Figure A demonstrates an AP radiograph of a pediatric femur with a short oblique, mid-shaft fracture. Illustration A demonstrates an AP and lateral Xray of a femur after intramedullary nailing with flexible nails.

Incorrect Answers:
Answer 1: Pavlik harness is more appropriate for patients less than 6 months.
Answer 2: Closed reduction and spica casting is more appropriate for patients less than five years of age.
Answer 4: This fracture can likely does not require open reduction to pass the nails.
Answer 5: Closed reduction and rigid intramedullary nailing is more appropriate for patients 11 years of age or older (though safety has been demonstrated in younger patients).