What are the implications of a femoral subchondral impaction fracture in a pediatric patient?

From the Guidelines

In pediatric patients with a femoral subchondral impaction fracture, it is recommended to initially manage the condition conservatively with a period of non-weight bearing and pain management, as surgical options such as microfracture 1 may not be necessary for all cases.

Initial Management

• Acetaminophen (15 mg/kg/dose every 4-6 hours) or ibuprofen (10 mg/kg/dose every 6-8 hours) can be used for pain control, as these medications are commonly used for pain management in pediatric patients.
• For patients with significant pain or discomfort, a short course of narcotic pain medication such as oxycodone (0.1-0.2 mg/kg/dose every 4-6 hours) may be considered, but this should be used with caution and under close supervision due to the risk of addiction and side effects.

Immobilization and Physical Therapy

• Immobilization with a brace or cast may be necessary to reduce stress on the affected area, allowing the fracture to heal properly.
• Physical therapy can be initiated once the pain has subsided to improve range of motion and strength, which is essential for preventing long-term disability and promoting proper healing.

Surgical Intervention

• In cases where conservative management fails or the fracture is unstable, surgical intervention may be necessary to stabilize the fracture and promote healing, as seen in cases of femoroacetabular impingement (FAI) 1.
• Close follow-up with an orthopedic specialist is essential to monitor the healing process and adjust treatment as needed, as pediatric patients with femoral subchondral impaction fractures may require referral to a pediatric orthopedic surgery specialist 1.

Underlying Cause Investigation

• It is also important to investigate the underlying cause of the fracture, such as osteoporosis or a metabolic bone disease, and manage these conditions accordingly to prevent future fractures, as certain conditions may increase the risk of fractures in pediatric patients.
• Calcium and vitamin D supplements may be recommended to support bone health, as these nutrients are essential for proper bone development and healing.

From the Research

Implications of Femoral Subchondral Impaction Fracture in Pediatric Patients

• The implications of a femoral subchondral impaction fracture in a pediatric patient can be significant, with potential for long-term effects on bone health and joint function 2, 3.
• Subchondral fractures of the femoral head have been reported in pediatric patients, with clinical and radiographic characteristics including pain, limited mobility, and abnormal imaging findings 2.
• The treatment of subchondral fractures in pediatric patients typically involves conservative management, including rest, physical therapy, and pain management, although surgical intervention may be necessary in some cases 4, 3.
• The risk factors for subchondral fractures in pediatric patients are not well established, but may include osteoporosis, osteopenia, and trauma 5, 3.
• The prognosis for pediatric patients with subchondral fractures is generally good, with most patients experiencing complete healing and return to normal activity, although some may experience long-term sequelae such as residual deformity or osteoarthritis 2, 3.

Treatment Options

• Conservative treatment, including rest, physical therapy, and pain management, is often the initial treatment approach for pediatric patients with subchondral fractures 2, 3.
• Surgical treatment, including the use of submuscular bridge plates, may be necessary in some cases, particularly for length-unstable or complex fractures 4.
• The choice of treatment depends on the individual patient's condition, including the location and severity of the fracture, as well as the patient's age and overall health 6, 4.

Complications and Long-term Effects

• Pediatric patients with subchondral fractures may be at risk for long-term complications, including osteoarthritis, residual deformity, and chronic pain 2, 3.
• The risk of osteonecrosis, a potentially devastating complication, appears to be low in pediatric patients with subchondral fractures, although close monitoring and follow-up are necessary to detect any potential problems 2, 3.