Ortho Dx: Thigh pain after fall - Clinical Advisor

Ortho Dx: Thigh pain after fall

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A patient, aged 2 years, presented to the emergency department (ED) after falling off his bed at home.

The patient was unable to bear weight and his parent’s stated he was pointing and holding his left thigh. On exam, the patient was in obvious discomfort.

This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.

Treatment of pediatric femur fractures is largely dependent on age. Newborn aged up to six months can be treated with a Pavlik harness, as the thick periosteum in this age group provides fracture stability. The straps on the Pavlik harness...

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Treatment of pediatric femur fractures is largely dependent on age. Newborn aged up to six months can be treated with a Pavlik harness, as the thick periosteum in this age group provides fracture stability. The straps on the Pavlik harness and/or a thigh wrap can help reduce a displaced fracture. Fractures with significant displacement or angulation may require a hip spica cast.

For patients aged 7 months to 5 years, early hip spica casting is recommended for femoral shaft fractures with less than 2 to 3 cm of shortening. The hip spica cast is applied under anesthesia or sedation to aid in fracture reduction.

The technique involves first applying a short leg cast with the patient’s foot in a neutral position. The hip is then flexed to 60 to 90 degrees and 30 degrees of abduction. The leg is often externally rotated 15 degrees to help align the distal fragment to the externally rotated proximal fragment. The knee is then placed in 60 to 90 degrees of flexion and the short leg cast is extended to the proximal thigh, hip and circumferentially around the lower abdomen.

The cast is extended to the supracondylar area of the contralateral leg. This is often referred to as a 1-1/2 leg type hip spica cast. Water resistant padding is placed on the cast edges around the groin to prevent skin problems. Fluoroscopy is used to reduce the fracture and maintain alignment during cast application. A “broomstick” may be applied between the two thighs if structural support to the cast is necessary. The cast is worn for 4 to 8 weeks depending on patient age and fracture displacement.

In femur fractures with significant shortening (>2 to 3 cm) traction to the distal femur may be necessary. Traction is used for 2 to 3 weeks until early callus formation is present. A hip spica cast is then applied when traction is taking off.

Flexible intramedullary nailing is indicated in femur fractures occurring in patients aged 6 to 10 years. Unstable comminuted or spiral femur fractures in this age group may require open reduction and internal fixation with submuscular bridge plating.

Treatment of femur fractures in patients aged over 11 years and approaching skeletal maturity is often determined by weight and fracture stability. Stable fractures in patients weighing less than 100 pounds are often treated with flexible intramedullary nailing. Stable femur fractures in patients weighing over 100 pounds can be treated with intramedullary nailing. Unstable fractures both very proximal and distal should be treated with open reduction and internal fixation.

Dagan Cloutier, MPAS, PA-C, practices in a multispeciality orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants (JOPA).

References

  1. Beaty JH, Kasser JR. (2006). Rockwood and Wilkins’ Fractures in Children (6th Edition.). Philadelphia, PA: Lippincott Williams & Wilkins.
  2. Souder C. (2014). Femur fractures – pediatric. Orthobullets. Retrieved from http://www.orthobullets.com/pediatrics/4019/femur-fractures–pediatric

All electronic resources were accessed on 3/16/2015.

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