What is the recommended splinting type for an impacted distal femoral metaphysis fracture in a 2-year-old?

Splinting for Impacted Distal Femoral Metaphysis Fracture in a 2-Year-Old

A long leg splint with the knee in slight flexion is the recommended initial splinting method for an impacted distal femoral metaphysis fracture in a 2-year-old, followed by consideration for functional bracing once swelling subsides.

Initial Assessment and Considerations

When managing distal femoral metaphyseal fractures in young children, several important factors must be considered:

• Distal femoral metaphyseal fractures in children under 2 years require careful evaluation for potential child abuse, particularly in non-ambulatory children 1
• Impacted transverse fractures of the distal femoral metaphysis can occur from short falls to the knee in young children 1
• The type of immobilization depends on fracture stability, displacement, and patient age

Recommended Splinting Approach

Initial Immobilization

• Long leg posterior splint with knee in 15-30° flexion
  • Provides adequate stabilization while allowing for swelling
  • Ensures proper alignment of the impacted fracture
  • Avoids excessive pressure on the popliteal fossa 2

Progression to Definitive Treatment

After initial swelling subsides (typically 3-7 days):

1. For minimally displaced impacted fractures:

   • Functional femur bracing is recommended as it:
     • Eliminates need for casting and anesthesia
     • Allows for easy adjustment and hygiene
     • Permits early motion and controlled weight-bearing 3
     • Provides optimal positioning of the hip in flexion and abduction

2. For unstable or significantly displaced fractures:

   • Consider 90-90 spica casting under sedation or anesthesia
   • Particularly effective in children under 6 years with closed femoral shaft fractures 4

Duration of Immobilization

• Typical immobilization period: 4-6 weeks
• Limiting immobilization duration reduces complications like joint stiffness 2
• Regular radiographic follow-up at 1,2, and 4 weeks to assess healing and alignment

Special Considerations

• Child Abuse Screening: While impacted distal femoral metaphyseal fractures can occur from accidental mechanisms in toddlers, complete metaphyseal fractures in pre-walking children should raise suspicion for abuse 5
• Growth Plate Concerns: Careful monitoring is needed due to proximity to the distal femoral physis
• Early Mobilization: Once stable, directed home exercise program with active motion exercises helps prevent stiffness 2

Pitfalls to Avoid

• Excessive immobilization: Can lead to joint stiffness and muscle atrophy
• Inadequate padding: Particularly in the popliteal fossa, which can cause pressure sores
• Figure-of-eight bandages: A simple arm sling is preferred over figure-of-eight bandages for upper extremity immobilization 2
• Delayed follow-up: Regular assessment of healing and alignment is crucial to prevent malunion

Conclusion

For a 2-year-old with an impacted distal femoral metaphysis fracture, initial management with a long leg splint followed by transition to functional bracing offers the best balance of fracture stabilization, comfort, and functional recovery while minimizing complications.