BROKEN LEG (THIGH BONE)
Pediatric FEMUR FRACTURE
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What is a Broken Leg in a Child (femur fracture)?
People refer to a "broken leg" as either a broken thigh bone (the femur bone) or a broken shin bone (your tibia). We will discuss the broken thigh bone (femur) in this talk. Remember that a Broken Bone is the same thing as a Fracture....like a "car" and an "automobile" refer to the same thing.
The femur is our thigh bone and its the biggest bone in our body, and its also a very strong bone. Therefore, you can imagine that it takes a lot of force to break this bone. In kids, this injury is usually seen in two different age groups: 1) toddlers: as they learn to walk they can fall off a couch or stairs, or twist their leg to cause this injury; and 2) teenagers: as we all know, adolescents are driving fast, and doing other things that put their bodies at harm for traumatic injury.
How is a Broken Leg in a Child diagnosed?
Kids with this injury come into the emergency room after a car accident (teenagers) or significant fall (toddlers or young children), and are feeling significant pain in their thigh. They are unable to put any weight on the leg. Sometimes the leg can be bent in the wrong direction, and its obvious that the femur is broken.
X-rays alone will diagnose the fracture. X-rays of the hip and knee (the joint above and below the femur) should also be taken to look for other injuries. X-rays usually provide all of the necessary information. CAT scans are rarely needed (which is great because this exposes kids to much higher doses of radiation). Similarly, MRIs are not typically required for this injury.
How is a Pediatric Femur Fracture treated (Surgery versus No surgery for a Broken Leg in a Child)?
All adults need surgery for a femur fracture. But this is not true in kids. Kids are growing and their bones are very motivated to heal quickly! Therefore, most kids under 5 years old do not need surgery. These kids require a cast that fully protects the broken bone while it heals. This isn't any ordinary cast either, its a SUPER CAST (also known as a Spica Cast). Its really big and so most kids really don't like it (thats the understatement of the century). Kids can't run and play with their friends, but most parents agree that a cast is better than surgery, and a kid with a broken leg should not be trying to run around anyway.
Occasionally a kid (under 5 years old) will need surgery anyway because the bone is broken in a way that its very unstable and a cast alone cannot hold it in position while it heals. Similarly, older kids cannot tolerate a "spica cast" because its so uncomfortable and limiting that it will drive them crazy! So what surgical treatments recommended for these older kids, or young kids with unstable fractures.
The surgery depends on the kid. How old is the child, how much do they weigh. It also depends on the location of the break, and how many pieces the bone has broken into. Kids younger than 11 years old that weigh under 100 lbs are treated with two long pins that go in the center of the bone, and hold it in position while the bones heal. These pins are then pulled out after about 9 months (once the bone is total healed). Kids younger than 11 years old that weigh over 100 lbs, or kids that have a bone broken into many pieces are treated with a metal plate and screws. This type of surgery offers more stability to the broken bone while it heals. The plate and screws usually on the bone forever, unless the child or parents really want it taken out.
Kids older than 11 years old (this is the teenagers) are usually treated with metal rod that goes down the center of the bone. The rod is stronger than the flexible pins used in younger children. The rod is so strong in fact, that most kids are allowed to start walking on their leg only a few days after surgery. This type of rod is the same surgery that most adults get, with only one small variation. Adults get a straight rod, while kids get a rod that is slightly bowed. This is because the rod is inserted in different places along the femur bone.
What is the long term outcome?
The bone will heal in > 95% of cases, when the correct treatment is selected by the doctor.
All injuries have some risk of complications. In children < 10 years old, their bone is so motivated to grow, that after an injury like a broken femur, the bone doesn't just return to normal but it actually grows a little extra so it will be a few milimeters longer than the other leg after everything has healed. Kids rarely notice this difference, , and if they do, there are treatments available.
The risk of infection is low, less than 1%, and this is partly because the incision is very small, and also because the femur has a good blood supply that allows our immune system to quickly respond to any bacteria.
Reference
1. An Anatomic Study of the Greater Trochanter Starting Point for Intramedullary Nailing in the Skeletally Immature. Park PJ, Weinberg DS, Petro KF, Liu RW. J Pediatr Orthop. 2015
2. A systematic review of rigid, locked, intramedullary nail insertion sites and avascular necrosis of thefemoral head in the skeletally immature. MacNeil JA, Francis A, El-Hawary R. J Pediatr Orthop. 2011
3. Current concepts in pediatric femur fracture treatment. Kanlic E, Cruz M. Orthopedics. 2007.
4. Elastic nailing for pediatric subtrochanteric and supracondylar femur fractures. Parikh SN, Nathan ST, Priola MJ, Eismann EA. CORR 2014.
5. Immediate single-leg spica cast for pediatric femoral diaphysis fractures. Epps HR, Molenaar E, O'connor DP. J Pediatr Orthop. 2006
6. Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children. Flynn JM, Luedtke LM, Ganley TJ, Dawson J, Davidson RS, Dormans JP, Ecker ML, Gregg JR, Horn BD, Drummond DS. J Bone Joint Surg Am. 2004
7. Pediatric Diaphyseal Femur Fractures: Submuscular Plating Compared With Intramedullary Nailing. Sutphen SA, Mendoza JD, Mundy AC, Yang JG, Beebe AC, Samora WP 3rd, Klingele KE. Orthopedics. 2016
8. Clinical and Radiographic Outcomes After Submuscular Plating (SMP) of Pediatric Femoral ShaftFractures. Stoneback JW, Carry PM, Flynn K, Pan Z, Sink EL, Miller NH. J Pediatr Orthop. 2016