What is the postoperative care plan for a 5-year-old patient who has undergone flexible intramedullary nail (IMN) surgery for a femur fracture?

Postoperative Care for Flexible Intramedullary Nail Surgery in a 5-Year-Old with Femur Fracture

For a 5-year-old following flexible intramedullary nail fixation of a femur fracture, initiate immediate multimodal analgesia with scheduled acetaminophen, begin early mobilization within 24-48 hours with protected weight-bearing, and plan for nail removal at 6-12 months post-fracture union.

Immediate Postoperative Pain Management

Multimodal non-opioid analgesia forms the foundation of postoperative care:

• Administer acetaminophen 15 mg/kg every 6 hours routinely as baseline treatment, which decreases supplementary analgesic requirements 1
• Add ibuprofen (10 mg/kg every 6-8 hours) unless contraindicated by renal dysfunction or bleeding risk 1
• Reserve opioids strictly for breakthrough pain unresponsive to non-opioid analgesics, using reduced doses and frequency 1
• Include pain evaluation as part of routine nursing observations, as pain requirements fluctuate significantly during mobilization 1

Critical pitfall: Never use opioids as the sole analgesic adjunct due to increased risk of respiratory depression and postoperative confusion 2, 1

Weight-Bearing and Mobilization Protocol

Early mobilization is essential but must be carefully titrated in young children:

• Begin mobilization within 24-48 hours postoperatively to prevent thromboembolism and improve rehabilitation outcomes 3, 4
• Initial weight-bearing status should be non-weight bearing or toe-touch weight bearing for the first 2-4 weeks 5
• Progress to partial weight bearing (25-50% body weight) at 4-6 weeks based on radiographic callus formation 5
• Advance to full weight bearing at an average of 10 weeks, though this varies by fracture pattern and stability 5
• Expect radiographic union at approximately 10-11 weeks 5

For a 5-year-old specifically: Children under 10 years have significantly lower complication rates (9%) compared to older children (34%), allowing for more aggressive mobilization protocols 5

Immobilization and Support

External support requirements depend on fracture stability:

• Use a hip spica cast or knee immobilizer for the first 2-4 weeks in approximately 60% of cases, particularly for length-unstable or comminuted fractures 5, 6
• Remove external support once early callus formation is evident on radiographs, typically at 3-4 weeks 6
• For highly unstable fractures, consider augmentation with external fixation for 4 weeks to provide additional rotational and longitudinal stability 6

Range of Motion Monitoring

Expect rapid recovery of joint mobility:

• Hip flexion returns to baseline (0-degree loss) by 3 months postoperatively 5
• Knee flexion shows minimal loss (average 4 degrees) by 6 months 5
• Hip internal/external rotation and knee extension demonstrate minimal postoperative loss 5
• Begin gentle passive range of motion exercises once pain is controlled, typically within the first week 5

Radiographic Follow-Up Schedule

Serial radiographs are essential to monitor alignment and union:

• Obtain radiographs immediately postoperatively, at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months 5
• Monitor for malunion (>5 degrees varus or >7 degrees anterior angulation), which occurs in up to 44% of cases but rarely causes clinical problems 7
• Assess leg length discrepancy at each visit; expect >1 cm discrepancy in some patients at 6-12 months, though most resolve spontaneously 5
• Watch for delayed union or refracture, particularly in the first 3 months 8, 7

Complication Prevention

Specific technical factors reduce complication risk:

• Ensure nail ends are advanced to lie against the supracondylar flare to prevent pain and irritation at insertion sites (the most common complication at 41%) 8
• Avoid using nails of mismatched diameters, which increases malunion risk 19-fold 8
• Monitor comminuted fractures (>25% comminution) carefully, as they have 5.5-fold increased risk of loss of reduction 8
• Consider additional immobilization for comminuted or length-unstable fractures 8

Activity Restrictions and Return to Normal Function

Progressive activity advancement:

• Restrict high-impact activities (running, jumping, contact sports) for the first 3 months 5
• Allow return to preoperative activity level at an average of 4.9 months 5
• Permit full unrestricted activity once radiographic union is complete and the child is pain-free 5

Hardware Removal Planning

Nail removal is recommended but timing is debated:

• Plan for elective nail removal at 6-12 months after fracture union 9
• Approximately 25% of patients ultimately require nail removal due to persistent discomfort even without scheduled removal 9
• Up to 50% of patients report residual non-debilitating pain at 2-5 years regardless of nail presence 9
• Pain/irritation at insertion sites occurs in 41% of cases and is the primary indication for early removal 8

Supportive Care Measures

Address nutritional and fluid status:

• Encourage early oral fluid intake rather than routine IV fluids, as hypovolemia is common 2, 4
• Assess nutritional status, though malnutrition is less common in pediatric trauma than elderly hip fracture patients 2
• Remove urinary catheters (if placed) as soon as possible to reduce infection risk 2, 4

Expected Outcomes in Young Children

Prognosis is excellent for 5-year-olds:

• Complication rate of only 9% in children under 10 years, compared to 34% in children ≥10 years 5
• All fractures should achieve union without need for reoperation in uncomplicated cases 7
• Full range of motion in hip and knee expected after nail removal 7
• Leg length discrepancies typically resolve spontaneously and rarely require intervention in this age group 5, 7