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Guideline in Focus: Pediatric Femur Fracture
Nathan Kreykes MD, John Petty MD, Rosemary Nabaweesi DrPH, MBChB, Bettina Gyr MD, Shannon W. Longshore MD

Key Guideline Reference:
American Academy of Orthopaedic Surgeons (AAOS). American Academy of Orthopaedic Surgeons clinical practice guideline on treatment of pediatric diaphyseal femur fractures. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2015 Jun 12. 102 p. [50 references]

Link to guideline: Clinical Practice Guideline on Treatment of Pediatric Diaphyseal Femur Fractures

Guideline Highlights:
This guideline was originally developed by the American Association of Orthopedic Surgeons in 2009. A recent reissue was updated and published in 2015 to address management of isolated pediatric diaphyseal femur fractures. The 2015 edition added recent literature and removed inconclusive recommendations due to lack of evidence. The results are seven evidence based recommendations that range in strength of recommendation from strong to limited.

The single strongest recommendation is that children younger than thirty-six months with a diaphyseal femur fracture should be evaluated for child abuse.

The expert opinion of the work group found that regional pain management complications are less than that of IV or oral pain management. The evidence for this recommendation received a limited grade.

The remaining recommendations discuss interventions and practice consideration for treating femur fractures based on the child’s age and address Pavlik harness, spica casting, flexible intramedullary nailing, rigid trochanteric entry nailing, and submuscular plating.

The work group acknowledges that this was not developed to be a fixed protocol and encourages clinicians to use their best medical judgement and patient circumstances to develop care plans for patients.

What’s New?
Three recent publications contribute to our understanding of pediatric diaphyseal femur fracture management.

Article 1: Baker MD, Gullett JP. Ultrasound-Guided Femoral Nerve Blocks. Pediatr Emerg Care. 2015 Dec;31(12):864-8.

Link to article: Ultrasound-Guided Femoral Nerve Blocks

Children with femur fractures have severe acute pain associated with the injury. Both the fracture itself and the associated quadriceps spasm contribute to this pain. The femoral nerve provides sensory innervation to the anterior and medial thigh, femur, and knee. Femoral nerve blockade can provide excellent analgesia in the acute setting. This recent article reviews the relevant anatomy, pharmacology, clinical points, and technical instruction for performing ultrasound-guided femoral nerve blocks. This review is a helpful educational adjunct for providers in the emergency department setting who wish to learn to perform femoral nerve blocks from providers who are credentialed to teach this technique. A brief literature review supports femoral nerve blockade in pediatric patients as a means to improving pain scores and decreasing use of opiate pain medication. This review supports the use of femoral nerve blockade outside of the operating room setting.

Article 2: Blatz, A. M., Gillespie, C. W., Katcher, A., Matthews, A., & Oetgen, M. E. Factors Associated With Nonaccidental Trauma Evaluation Among Patients Below 36 Months Old Presenting With Femur Fractures at a Level-1 Pediatric Trauma Center. Journal of Pediatric Orthopedics. 2016 p1-6.

Link to article: Factors Associated with Non Accidental Trauma (NAT)

The aim of this was to identify areas of improvement in compliance with the American Academy of Orthopedic Surgeons published clinical practice guidelines (CPGs). Medical records were reviewed for documentation of a NAT evaluation, patient characteristics, presence of other fractures or injuries, and hospital of presentation. Radiographs were reviewed for fracture pattern. Statistical analysis was performed to assess for differences overall and before and after CPG publication. 281 children below 36 months presented with femur fractures; 41% were evaluated for NAT. Overall, the following factors were significantly associated with receipt of a NAT evaluation: transfer from an outside facility, and identification of another fracture. Before publication of the CPG, nonwhite patients were much more likely to undergo NAT evaluation compared with white patients. After publication of the CPGs, this differential disappeared. The utilization of NAT evaluation for patients below 36 months old presenting with femur fractures was poor. Despite CPG publication, only modest improvements in this evaluation improved. Younger children, patients transferred from other institutions, and patients presenting with concomitant fractures were more likely to undergo NAT evaluation.

Article 3: Murphy R, Kelly DM, Moisan A, Thompson NB, Warner WC, Beaty JH, Sawyer JR. Transverse fractures of the femoral shaft are a better predictor of nonaccidental trauma in young children than spiral fractures are. J Bone Joint Surg A m 2015 Jan 21; 97(2): 106-11.

Link to article: Transverse Fractures of Femoral Shaft Predict NAT

This is a prognostic study that set out to determine if fracture morphology (by Fracture ratio) is indicative of non-accidental trauma (NAT) in young children with a femoral fracture. Patients included in this study were less than or equal to 3 years old and had a closed isolated femur fracture, and were managed at a level I pediatric trauma center. The fracture ratio (FR) is calculated by dividing maximum length of fracture by the bone diameter at fracture site. Fractures with lower ratios-closer to 1 are more transverse and those with higher ratios are more spiral.

Interobserver agreement with FR was good (Kappa=0.6) for pediatric orthopedic surgeons. And K>70% for all specialty for transverse fractures w/ FR <1.47 and spiral fractures with FR >3.45 A pediatric-trained orthopedic surgeon who was blinded to the clinical history calculated AP & lateral Fracture ratios. This study found children with NAT had significantly, reduced anteroposterior and lateral FR compared to those who had accidental trauma. Transverse fractures were more associated with NAT. One can conclude from this study that a FR should be used as part of a comprehensive multidisciplinary NAT assessment team and the presence of a transverse diaphyseal femoral fracture should raise suspicion of NAT in a young child.

A Pediatric Orthopaedic Surgeon’s Perspective
These guidelines summarize established practice patterns and accepted treatment of pediatric diaphyseal femur fractures. They also illustrate the scarcity of Level I evidence studies in the literature and the difficulty in performing such studies involving children.

The AAOS provides 7 recommendations, only one based on “strong evidence”, one based on moderate evidence, and the remaining 5 based on limited evidence.

The strongest evidence supports the evaluation of children under age 3 years with diaphyseal femur fractures for child abuse. This recommendation should be considered strongly, especially for non-ambulatory and non-verbal children (under age 1), where 12-13% of femur fractures have been found to be the result of abuse. Estimates find that child abuse is under-reported and the consequences of missing it can result in serious long-term physical and social complications.

Moderate evidence exists for spica cast treatment of diaphyseal femur fractures in children ages 6 months to 5 years. In my practice, I have found a single leg spica cast provides sufficient immobilization for healing and allows for children to fit into their existing car seats and return to daycare.

The limited evidence for the remaining treatment modalities reflect the paucity of prospective Level 1 studies of these modalities and changing patient characteristics. Many of the recommendations regarding implants are based on age and weight of the child, but this is often difficult to adhere to with current rates of childhood obesity. The recommended patient weight limit for using flexible intramedullary nails is 100 pounds. Although these implants are recommended for ages 5-11 years, many children in the upper part of this age range weigh well over 100 pounds. This then leads to use of submuscular plates or rigid trochanteric entry nails in children under age 11. Many children also participate in “high risk, high speed” activities and suffer adult pattern fractures at a young age. This also necessitates using more rigid, adult-type implants such as plates and nails.

While these guidelines are helpful and well written, care must be taken when applying them broadly and rigidly. Keeping in mind that most have limited evidence and limited recommendation by the AAOS Evidence Based Quality and Value Committee – they are simply a guideline to treat children and must be individualized appropriately for the child, the family, the type and pattern of fracture, and the surgeon’s ability.

Bettina M. Gyr, M.D.
Brenner Children’s Hospital
Wake Forest Baptist Health
Winston Salem, NC

What do you think? Does your institution treat children according to the AAOS guideline? What pearls and pitfalls do you have?

PTS would love to hear from you. If you want to submit your femur fracture management pathway, email it to guidelines@pediatrictraumasociety.org.

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Keep an eye on the PTS website for new ideas and ways to make the care of injured kids better.

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