Fractures - Femur

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim 

To guide PCH ED staff in the assessment and management of femur fractures in children.

Background

  • Femoral shaft fractures are more common than other parts of the femur
  • Consider non-accidental injury in femoral shaft injuries in infants
  • Shock is never the result of a single femoral shaft fracture in children – look for another site of haemorrhage.

General

  • Femur fractures account for approximately 1.5% of paediatric fractures
  • Incidence is most common in the 2 – 3 year age group and adolescence
  • Consider non-accidental injury. Complete an Injury Proforma form in children < 2 yrs age
  • Neurovascular examination should be performed regularly
  • Look for other injuries if the mechanism is due to a motor vehicle accident or there is concern for non-accidental injury.

Assessment

History

  • The most common mechanism of injury for early childhood is a fall resulting in a twisting injury or a direct blow
  • Sports and motor vehicle accidents are the most common mechanism of injury for adolescents
  • In infants, femoral shaft injuries should raise suspicion of non-accidental injury. A careful and detailed history should be taken in these cases. Complete an injury proforma sheet for children < 2 years age

Examination

  • There is usually pain and swelling of the thigh with reluctance to move the hip and knee joints
  • Assess for neurovascular compromise and open wounds.

Investigations

Radiology

  • The entire femoral shaft including hip and knee joints should be X- Rayed
  • Assess angulation and alignment
  • Look for dislocation of the hip
  • For description of types of fractures see Fractures – Overview
  • A femoral nerve block provides effective analgesia
  • If distal pulses are compromised, seek urgent Orthopaedic team review
  • Perform a primary survey if the mechanism of injury is a high impact trauma
  • All femoral fractures should be referred to the Orthopaedic team.

Management

Resuscitation

  • If the mechanism of injury is due to high impact trauma or MVA, life-threatening injuries should be assessed and treated before dealing with the femoral fracture. See Serious injury.
  • Shock does not occur in isolated femoral fractures – look for other sources of bleeding.

Initial management

  • Analgesia. Often need opioids (e.g. intranasal fentanyl) and femoral nerve block
  • Examine for neurovascular injury (if deficits evident manage immediately) – urgent Orthopaedic team referral
  • Immobilise suspected fracture before X-Rays (e.g. splint, board)
  • Keep fasted pending Orthopaedic review
  • Antibiotics for compound fractures and consider tetanus.

Further management

Proximal femur

  • In children, proximal femoral fractures (physeal, intertrochanteric and femoral neck fractures) are less common than femoral shaft fractures but have higher rates of complication (osseous necrosis)
  • All proximal femoral fractures should be referred to the Orthopaedic team for further management
  • Slipped Upper (or Capital) Femoral Epiphysis (SUFE) usually presents in adolescents with a history of chronic hip or knee pain but may also present acutely with trauma
    • Management involves strict bed rest, analgesia and Orthopaedic team referral for pinning. See Limp and Hip Pain.
    • Hip dislocation is uncommon in children but may be associated with fracture. Early referral to the Orthopaedic team for reduction is important to reduce the incidence of osseous necrosis.

Shaft of femur

  • All femoral shaft fractures should be referred to the Orthopaedic Team
  • Younger children will need traction +/- hip spica and older children may need intramedullary rods to stabilise the fracture
  • Adequate analgesia including femoral nerve block is important while awaiting Orthopaedic team review
  • Traction splint should be applied once adequate analgesia has been given
  • Diazepam 0.2mg/kg orally is useful for muscle spasm and adjunct oral analgesia such as paracetamol, ibuprofen and/or oxycodone should be provided prior to transfer to the ward. See Analgesia.

Spiral fracture in a 3 month old was a result of NAI. Note 'Bucket Handle' appearance of distal metaphysis

 

Spiral fracture of femur in a 3 month old which was the result of NAI. Note "bucket handle" appearance of distal metaphysis (above).
Transverse fracture with displacement and shortening secondary to a MVA

 

Transverse fracture with displacement and shortening.

Fractures of femur requiring urgent orthopaedic referral

  • All fractures of the femur in children should be referred to the Orthopaedic Team
  • Urgent referral is needed for any fracture with neurovascular compromise.

Referrals and follow-up

  • All femoral fractures in children are referred to the Orthopaedic team and followed up in the Orthopaedic Fracture clinic. See Outpatients.

Endorsed by:  Director, Emergency Department   Date:  Jun 2017


 Review date:   Jun 2020


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