Slideshow
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Slide
X-rays of the femur of a 4-month-old girl following a fall
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Slide
X-rays of the femur of a 4-month-old girl following a fall
A 4-month-old girl is brought to the emergency department by her parents after a full day of inconsolable crying. The father reports that he had tripped while holding the child earlier in the day. He said he lost his balance and the child fell to the ground and began crying. Skeletal survey is performed and spiral fracture of the left femur is identified. The injury is determined to be nonaccidental trauma, and the infant is placed with child protective services.
This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.
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Child abuse should be suspected in any child aged less than 5 years who presents with a femur fracture, and in particular, in any child presenting with femur fracture before walking age. Child abuse is the most common cause of femur fracture in children aged less than 1 year.
Femur fractures that occur between ages 0 and 6 months are relatively stable injuries because of the thick periosteum present in this age group. Fractures in infants have remarkable remodeling potential and heal within 3 to 4 weeks without complications or long-term sequelae.
A Pavlik harness is the recommended treatment for femur fractures in infants aged 0 to 6 months. A Pavlik harness places the hip in moderate flexion and abduction, which helps align the distal fragment with the proximal fragment. The harness can be applied without anesthesia or sedation and the straps can be adjusted to help reduce the fracture. A Pavlik harness allows for diaper changes without removal, and the harness can be changed should it become soiled. Excessive hip flexion in the harness should be avoided to prevent femoral nerve injury, which may present as decreased quadriceps function. Hip spica casting may be considered for infants aged 0 to 6 months with fractures that are significantly shortened or angulated. Femur fractures without significant shortening in patients aged 7 months to 5 years are usually treated with early hip spica casting, whereas flexible intramedullary nails are used for the same fracture pattern in children aged 6 to 11 years.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
References
- Souder C. Femoral shaft fractures—pediatric. http://www.orthobullets.com/pediatrics/4019/femoral-shaft-fractures–pediatric. Accessed November 14, 2016.
- Beaty JH, Kasser JR. Rockwood and Wilkins’ Fractures in Children. 6th ed. Philadelphia, PA: Lippincott, Williams, & Wilkins; 2005.
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