Paediatric Acute care Guidelines PMH Emergency Department

This guideline is specific for the assessment and management of femur fractures

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 (A3 folded sheet located in the Doctor’s offices)

Assessment

  • 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

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. Do an injury proforma sheet for children < 2 years (A3 folded sheet located in the Doctor’s offices).

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:

Management

  • 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

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 Pain Stop (combination paracetamol/codeine syrup) and Ibuprofen should be provided prior to transfer to the ward. See Analgesia.
Spiral fracture of femur in a 3 month old was a result of NAI - also note 'Bucket Handle' appearance of distal metaphysis

Spiral fracture of femur in a 3 month old was a result of NAI – also note ‘Bucket Handle’ appearance of distal metaphysis

Transverse Fracture of Femur with displacement and shortening secondary to MVA

Transverse fracture of femur with displacement and shortening secondary to a MVA

 

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 Outpatient Clinics.

Health information (for carers)

Nursing

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