What to do with a 5-year-old patient 7 days postoperative from femur fracture surgery with flexible intramedullary nails (IMN) who refuses to move the operated leg despite no pain?

Management of Postoperative Reluctance to Move After Pediatric Femur Fracture Surgery

In a 5-year-old child 7 days post-flexible intramedullary nailing for femur fracture who refuses to move the leg despite no pain, immediately initiate gentle mobilization with reassurance and physical therapy support, as early mobilization is safe and beneficial in this population. 1, 2

Understanding the Clinical Context

This scenario represents a common behavioral response rather than a surgical complication in young children after femur fracture fixation with flexible nails:

• Weight bearing typically begins at 16.4 days (range 1-60 days) after flexible intramedullary nailing in preschool children, so day 7 falls within the expected early mobilization window 2
• The absence of pain is reassuring and suggests no acute complications such as compartment syndrome, infection, or hardware failure 3, 2
• Psychological reluctance to move is common in young children who may fear pain or simply need encouragement and demonstration that movement is safe 4

Immediate Assessment and Action Steps

Clinical Evaluation Required

• Confirm absence of complications: Check for swelling, warmth, erythema, fever, or any signs suggesting infection or hardware issues 3, 2
• Assess neurovascular status: Ensure intact sensation, motor function, and perfusion to rule out nerve injury or vascular compromise 4
• Evaluate range of motion passively: Gently move the hip and knee through range of motion to confirm no mechanical block or true pain with movement 4

Mobilization Protocol

Immediate weight bearing should be tolerated if there is correct gait pattern (with crutches if necessary) and no pain, effusion, or temperature increase when walking 5, 1:

• Start with passive range of motion exercises performed by the physical therapist or parent to demonstrate safety 4
• Progress to active-assisted exercises where the child participates with support 2
• Use play-based therapy techniques appropriate for a 5-year-old to encourage voluntary movement without focusing on the "injured" aspect 4
• Implement early mobilization protocols to reduce complications and improve outcomes 1

Weight-Bearing Guidance

The American Academy of Orthopaedic Surgeons recommends immediate weight-bearing as tolerated after flexible intramedullary nailing 1:

• Begin with touch-down weight bearing using crutches or walker for support 2
• Progress based on comfort and confidence rather than strict time-based protocols in this age group 4, 2
• Average time to full weight bearing is 10 weeks, but earlier partial weight bearing is safe and encouraged 4

Common Pitfalls to Avoid

• Do not allow prolonged immobilization: Extended bed rest increases risk of muscle atrophy, joint stiffness, and psychological dependence on non-weight bearing 5, 1
• Avoid over-reassuring about "no need to move yet": This reinforces the child's reluctance and delays rehabilitation 4, 2
• Do not dismiss parental anxiety: Parents may inadvertently encourage the child's reluctance if they fear causing harm 2

Expected Timeline and Outcomes

• Hospital stay averages 4-9 days for flexible intramedullary nailing in preschool children, so discharge planning should include home mobilization strategies 3, 2
• Range of motion rapidly improves postoperatively with minimal loss of hip flexion by 3 months and knee flexion by 6 months 4
• Return to preoperative activity level averages 4.9 months, but early mobilization accelerates this recovery 4
• Radiographic union occurs at mean 2.5 months (range 2-3 months) in preschool children with flexible nails 3

Practical Management Strategy

Implement a structured but gentle mobilization program:

• Day 7-14: Focus on passive and active-assisted range of motion exercises multiple times daily 4, 2
• Week 2-4: Progress to active range of motion and touch-down weight bearing with assistive devices 2
• Week 4-8: Advance weight bearing as tolerated, aiming for full weight bearing by 10 weeks 4
• Continue physical therapy until return to age-appropriate activities 1, 4

Ensure adequate analgesia with regular paracetamol to facilitate comfortable movement, though opioids should be used cautiously and minimally in this age group 1