What is the recommended treatment for a 9-year-old patient with autism spectrum disorder (ASD) who has an acute femoral shaft fracture?

Treatment of Acute Femoral Shaft Fracture in a 9-Year-Old with Autism

For a 9-year-old child with autism and an acute femoral shaft fracture, surgical treatment with flexible intramedullary nailing is the recommended approach, performed within 24 hours of injury to minimize complications and optimize recovery. 1, 2

Initial Management Priorities

Immediate Pain Control

• Administer a femoral or fascia iliaca nerve block using low-concentration local anesthetics as first-line intervention, which provides excellent analgesia without masking compartment syndrome symptoms 2
• Implement multimodal analgesia incorporating the nerve block to ensure adequate pain relief 2
• This is particularly critical in children with autism, who may have difficulty communicating pain and discomfort effectively 3

Hemodynamic Assessment

• Assess the child's physiological stability, including hemodynamic status, respiratory function, and any associated injuries 1
• In an isolated femoral shaft fracture with hemodynamic stability, active hemorrhage is not the immediate threat 2
• Consider tranexamic acid administration as part of the perioperative protocol to reduce blood loss 2

Definitive Surgical Treatment

Timing and Approach

Proceed with early definitive surgical stabilization within 24 hours using flexible intramedullary nailing to minimize complications including fat embolism syndrome, ARDS, and to optimize functional recovery. 1, 2

Rationale for Surgical Treatment in This Age Group

• Children aged 6-12 years represent a paradigm shift from traditional conservative management, with surgical treatment now preferred due to shorter hospital stays and earlier return to activity 4, 5
• Flexible intramedullary nailing is specifically recommended for length-stable fractures in this age group 5
• Surgery reduces malunion rates significantly compared to conservative treatment (71 fewer malunions per 1000 children treated surgically) 6
• Early stabilization within 24 hours prevents ongoing fat particle release from the fracture site and reduces inflammatory complications 1

Special Considerations for Autism

• Children with autism pose unique challenges and are at increased risk of complications, making interdisciplinary care integral to successful outcomes 3
• Surgical treatment is particularly advantageous in this population as it:
  • Reduces hospitalization time, minimizing disruption to routine 4
  • Allows earlier mobilization, which may be better tolerated than prolonged immobilization 4
  • Decreases the need for repeated manipulations or cast changes that may be distressing 5

Surgical Technique Specifics

Flexible Intramedullary Nailing

• This is the preferred method for length-stable femoral shaft fractures in children aged 6-12 years 5
• The procedure provides reliable fracture healing with good outcomes 4
• Elastic stable intramedullary nailing may reduce recovery time compared to other methods 6

Alternative Surgical Options

• Submuscular bridge plating (minimally invasive) should be reserved for comminuted fractures where flexible nailing is not suitable 5
• External fixation is reserved for open fractures or initial stabilization in polytrauma patients 5

Postoperative Management

Mobilization and Rehabilitation

• Begin mobilization as soon as fracture stability allows 1
• Early mobilization is crucial for rehabilitation and particularly important for children with autism who may struggle with prolonged immobility 1

Complication Monitoring

• Monitor vigilantly for compartment syndrome—never dismiss escalating pain as "normal" post-injury pain, as this is the cardinal sign requiring immediate fasciotomy 2
• Watch for fat embolism syndrome, infection, and malunion 1
• Implement comprehensive pain control with multimodal analgesia throughout recovery 1

Metabolic Screening

• Screen for underlying metabolic abnormalities including hypocalcemia and vitamin D deficiency, as these are associated with atraumatic fractures and may complicate healing in children with autism 3

Critical Pitfalls to Avoid

• Do not delay fracture stabilization beyond 24 hours in stable patients, as this increases risk of fat embolism syndrome and ARDS 1, 2
• Avoid dense regional anesthesia that could completely mask compartment syndrome; use low-concentration techniques instead 2
• Do not choose conservative treatment with spica casting for this age group unless there are compelling contraindications to surgery, as surgical treatment has become the standard of care 4, 5
• Do not underestimate the communication challenges in children with autism—establish clear pain assessment protocols and involve caregivers intimately in monitoring 3

Expected Outcomes

• Union rates of 97% within six months can be expected with appropriate surgical management 7
• Serious adverse events occur in approximately 56 more per 1000 children treated surgically compared to conservative treatment, but these are offset by significantly reduced malunion rates 6
• Average knee range of motion of 107 degrees is achievable 7
• Return to school and normal activities occurs earlier with surgical treatment compared to conservative management 4, 5