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Femoral shaft fracture - Fracture clinics
All femoral shaft fractures should be assessed by the nearest orthopaedic on call service to evaluate the need for reduction and type of stabilisation.
Any patient with a significant mechanism of injury should be assessed via Advanced Trauma Life Support (ATLS) principles.
Femoral shaft fractures should be put into skin traction (10% of body weight) to help with pain management.
If the patient is to be transferred to another hospital, the leg should be immobilised in a Thomas type splint (if available) or a backslab.
Children that sustain femur fractures prior to walking age should be screened for non-accidental trauma.
Femoral shaft (diaphyseal) fractures can be classified according to:
Femoral shaft fractures represent approximately 1.6% of all pediatric fractures. It peaks in early childhood and early adolescence.
In older children, high energy trauma (e.g. motor vehicle accidents) is the mechanism of injury 90% of the time. In younger children, these fractures are usually due to falls. In children under four years of age, up to 30% of femur fractures are associated with non-accidental trauma. In children that are not yet walking, non-accidental trauma must be ruled out.
The thigh will be swollen and deformed. Any movement through the leg will result in significant pain.
Anteroposterior (AP) and lateral x-rays of the femur should be ordered. The x-rays must show the full length of the femur (including hip and knee joint).
Figure 1: AP and lateral x-ray of the femur demonstrating a complete fracture of the femoral diaphysis.
Femoral shaft fractures should be put into skin traction (~10% of body weight) to help with pain management. All femoral shaft fractures should be assessed by the nearest orthopaedic on call service to evaluate the need for reduction and type of stabilisation.
All femoral shaft fractures should be referred for an urgent orthopaedic assessment in the ED.
Other indications for prompt consultation include:
Any patient with a significant mechanism of injury should be assessed via Advanced Trauma Life Support (ATLS) principles. Skin traction with approx 10% body weight should be applied. A femoral nerve block can be performed to help with pain management.
Age, fracture pattern, fracture location, soft-tissue trauma and presence of associated injuries all influence the treatment modality (Table 1).
Table 1: Treatment options for femoral shaft fractures by age.
Orthopaedic treatment options
≤ 6 months
Immediate spica cast
6 months to 5 years
Immediate spica cast
Traction → spica cast
Flexible intramedullary nailing
11 years - skeletal maturity
Rigid trochanteric entry nailing
Flexible intramedullary nail (only if <50 kg)
Any follow-up should be arranged by the orthopaedic service.
Outcomes for shaft fractures are generally good.
See fracture clinics for other potential complications.
Kocher MS, Sink EL, Blasier RD, Luhmann SJ, et al. Treatment of pediatric diaphyseal femur fractures. J Am Acad Ortho Surg 2009; 17(11): 718 -25.
Flynn JM, Skaggs DL. Femoral shaft fractures. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.797 -841.