What is the immediate management for a child with a spiral femur fracture and no pre-existing medical conditions?

Immediate Management of Spiral Femur Fracture in a Child

For a child with a spiral femur fracture and no pre-existing conditions, immediate management requires: (1) pain control and immobilization, (2) urgent evaluation for non-accidental trauma if the child is non-ambulatory, and (3) age-appropriate definitive treatment—typically spica casting for children under 6 years or surgical fixation for older children. 1, 2, 3

Critical Initial Assessment

Rule Out Non-Accidental Trauma First

• In non-ambulatory children, femoral fractures are more likely caused by child abuse than accidental injury 4, 5
• Spiral femoral fractures can occur from falls down stairs when a child lands with the leg folded or twisted underneath, but this mechanism requires the child to be ambulatory 4
• Perform skeletal survey in all children <12 months with fractures, and consider it for children 12-23 months depending on fracture type and mechanism 1
• Document any bruising patterns, point tenderness, and obtain detailed history about the injury mechanism 1
• Check serum calcium, phosphorus, alkaline phosphatase, and consider vitamin D levels to rule out metabolic bone disease 1

Immediate Stabilization

• Provide adequate analgesia and immobilize the extremity in a splint or traction 6, 3
• Perform complete neurovascular examination and document findings 1, 6
• Obtain AP and lateral radiographs of the entire femur including hip and knee joints 6, 3

Age-Based Definitive Treatment Algorithm

Infants (0-18 months)

• Pavlik harness is safe and effective for femoral fractures in this age group 2
• However, maintain high suspicion for abuse in non-ambulatory infants with femoral fractures 4, 5

Young Children (18 months to 6 years or <100 pounds)

• Spica casting is the treatment of choice—safe, effective, and allows fracture healing with excellent remodeling potential 2, 7, 3
• Accept more initial deformity than previously tolerated due to exceptional pediatric remodeling capacity 1
• Careful attention to casting technique is essential to avoid complications 2

School-Age Children (6-12 years)

• Operative treatment is usually preferred to decrease hospitalization time, reduce morbidity, and allow early return to school 7
• Flexible intramedullary nailing is recommended for length-stable spiral fractures in the central 2/3 of the diaphysis 2, 7
• Submuscular bridge plating (minimally invasive) is reserved for comminuted fractures 7
• External fixation is appropriate for open fractures or polytrauma patients 2, 7

Adolescents (>12 years)

• Surgical fixation is recommended—either rigid antegrade intramedullary nailing (if physes are closing) or flexible nailing 2, 7
• Plate fixation provides stable fixation addressing the entire femur length, with submuscular placement minimizing soft tissue concerns 2

Special Circumstances Requiring Surgical Treatment

Regardless of age, surgical treatment is indicated for 3:

• Multiple injuries or polytrauma
• Open fractures
• Fractures with coexisting vascular injuries
• Failed initial conservative treatment
• Head injury or obesity (where spica casting is impractical) 2

Critical Pitfalls to Avoid

• Do not miss non-accidental trauma in non-ambulatory children—skeletal survey is nearly universal in children <12 months 5, 1
• Do not assume all spiral fractures are from abuse—ambulatory children can sustain spiral femoral fractures from falls down stairs with leg twisting 4
• Avoid prolonged immobilization beyond what is necessary, as this leads to stiffness and delayed return to activities 1
• Do not routinely obtain follow-up radiographs unless clinically indicated (new trauma, increased pain, loss of motion) 1, 8
• Monitor for compartment syndrome, particularly in the acute phase—check for pain out of proportion, decreased perfusion, and neurovascular changes 6

Follow-Up Considerations

• Repeat skeletal survey at 2-3 weeks improves sensitivity for detecting additional fractures if abuse is suspected 1
• Minimize routine postoperative imaging—obtain only if it will change management 1
• Femoral shaft fractures comprise 1.6% of all pediatric bony injuries but are the most common pediatric orthopedic injury requiring hospitalization 6
• Goal is healed fracture while avoiding complications including nonunion, angular/rotational deformity, leg length discrepancy, infection, and growth plate disruption 6