Femoral shaft fractures represent approximately 1.6% of all paediatric fractures.

It peaks in early childhood and early adolescence.

Femoral shaft (diaphyseal) fractures can be classified according to:

Location – proximal, middle or distal third

Amount of displacement, angulation, and extent of shortening

Fracture pattern – transverse, oblique, spiral or comminuted

In older children, high energy trauma (e.g. motor vehicle accidents) is the mechanism of injury 90% of the time.

In younger children, these fractures are usually due to falls.

In children, less than four years of age, up to 30% of femur fractures are associated with non-accidental trauma.  In children that are not yet walking, non-accidental trauma must be ruled out.

The thigh will be swollen and deformed.  Any movement through the leg will result in significant pain.

Children that sustain femur fractures prior to walking age should be screened for non-accidental trauma.

Any patient with a significant mechanism of injury should be assessed via Advanced Trauma Life Support (ATLS) principles.

Anteroposterior (AP) and lateral x-rays of the femur should be ordered.

The x-rays must show the full length of the femur (including hip and knee joint).

Analgesia should be given.

Skin traction with approx 10% body weight should be applied.  A femoral nerve block can be performed to help with pain management.

If definitive intervention is delayed, the leg should be immobilized in a Thomas type splint (if available) or a back slab.

Age, fracture pattern, fracture location, soft-tissue trauma and presence of associated injuries all influence the treatment modality.

Acceptable position for femoral fractures:

Age <2 years: 30 degree varus/valgus, 30 degree flex/ext, 20 mm shortening

Age 2-5 years: 15 degree varus/valgus, 20 degree flex/ext, 20 mm shortening

Age 6-10 years: 10 degree varus/valgus, 15 degree flex/ext, 15 mm shortening

Age 11-maturity: 5 degree varus/valgus, 10 degree flex/ext, 10 mm shortening

Treatment options for femoral shaft fracture by age:

<6 months – Pavlik harness

6 months to 5 years – immediate spica cast or traction followed by spica cast

5-11 years – Flexible intramedullary nailing or submuscular plating

>11 to skeletal maturity – Rigid trochanteric entry nailing, submuscular plating and Flexible intramedullary nail (only if <45Kg).

Parents are explained about the need for operative intervention and the potential complications associated with the femoral shaft fracture.

Emphasized to follow up regularly and promptly follow the instruction of the treating doctor.

Outcomes for shaft fractures are generally good.

Leg length difference – femoral shaft fractures can overgrow up to 2 cm in the 2 years after the fracture.  The fracture can also heal in a shortened position.

Malunion – the fracture is at risk of malunion, dependent on location and method of stabilization.

Refracture – most common with short oblique/transverse fracture patterns. Also potential risk post-ex-fix or hardware removal.

Delayed/nonunion – more common with weight-bearing implants (e.g. plates, ex-fix).