Fracture Fridays: Getting a leg up on the competition

The Case

An 80 pound 12 year old soccer star tripped in a hole while challenging for the ball. Another player on the pitch stumbled in the same (big) hole and landed awkwardly on the first player’s leg. Even the fans on the next field over heard the snap. EMS was called and an obviously uncomfortable 12 year old male with intact distal foot pulses and sensation presents to your ED. You do what you normally do and get an X-Ray.

It looks fine, right?

The Diagnosis

OK, so obviously this is a midshaft femur fracture that is displaced and foreshortened. Despite the shortening it is an oblique fracture, which is leg-length stable (more on that in a minute). Overall though the prognosis is actually pretty good. Your initial management centers around pain control, and immediate Ortho consultation. If they are close by there is no need for traction. If you anticipate a long transport, or if there is neurovascular compromise then it should be considered. In addition to narcotics a long leg posterior splint can provide temporary support. Ultimately, this young man had some ‘Home Depot’ action performed and had a great recovery after placement of intramedullary nails.

Nailed it!

Overall the risk of complications is low with leg length discrepancy the most common. It usually appears within 2 years of the injury and Orthopedists will accept approximately 2cm of overgrowth or shortening in patients <11. Nonunion is very rare in little children, but can occur in kids older than 11 years who weigh more than 49kg.

Management

This fracture goes to the OR – nuff said. So, don’t all femur fractures go to the OR? Well, not so fast my friends. In contrast to adults, the management of midshaft femur fractures differs by age.

Under 6 months

Pavlik harness and early spica casting

7 months to 5 years

<2-3 cm shortening – early spica casting >2-3cm shortening, multiple/open fractures – Traction with delayed spica casting, ORIF, flexible nails or external fixator