Review Question - QID 212971

A 3-year-old with a femoral shaft fracture with minimal shortening may be treated with immediate spica casting.

Pediatric diaphyseal femur fractures are very common injuries. Treatment with a Pavlik harness or spica cast is preferred for children less than 6 months of age with any type of diaphyseal femur fracture. Spica casts are also the typical treatment for children aged 6 months to 5 years with a diaphyseal fracture with 2 cm or less of shortening. If the fracture shortens more than 2-3 cm during treatment, another treatment option should be used. Relative contraindications to spica casting also include open fractures and polytrauma.

Flynn et al. published an instructional course lecture on femoral shaft fractures. They report that, in order to determine which treatment option is best for a specific fracture type, fractures can be divided into five classes: (1) fractures that will heal with limited intervention; (2) fractures that should be treated without surgery, but must be watched closely; (3) fractures that benefit from surgical intervention with load-sharing implants; (4) fractures that may benefit from surgical intervention with rigid fixation; and (5) fractures in a patient with a limb at risk and associated injuries that require initial treatment precedence. Spica casting may be used as treatment for the first two categories.

Kocher et al. performed a review on the treatment of pediatric diaphyseal femur fractures. They report that patients less than 6 months may be treated with a spica cast or a Pavlik harness. Both of these modalities result in good outcomes with minimal complications. They conclude that treating with these modalities necessitates skin checks as skin complications may occur.

Illustration A is a table detailing the options for the treatment of pediatric femoral shaft fractures.

Incorrect Answers:
Answer 2: Though the patient is in the appropriate age range for spica casting, the fracture has significant shortening and other options including fixation or traction with delayed spica casting should be considered.
Answer 3: This injury would be best suited with submuscular bridge plating given the amount of shortening and the fracture’s length unstable character.
Answer 4: This patient would benefit most from flexible IMN fixation given their age and fracture characteristics.
Answer 5: This injury would require I&D with delayed spica casting when swelling has appropriately diminished.