What is the appropriate evaluation and management for a proximal femur fracture in a 3‑year‑old boy?

Management of Proximal Femur Fracture in a 3-Year-Old Boy

In a 3-year-old with a proximal femur fracture, immediate immobilization and pain control are essential, followed by urgent orthopedic consultation for surgical fixation, as pediatric femoral fractures in this age group typically require operative management to prevent complications and ensure proper healing.

Initial Evaluation and Stabilization

Clinical Assessment

• Examine for the classic triad: shortened leg, external rotation, and inability to weight-bear, which are pathognomonic findings even before radiography 1
• Assess neurovascular status of the affected limb to rule out vascular injury or compartment syndrome 2
• Evaluate for associated injuries, particularly in high-energy trauma mechanisms 3

Immediate Pain Management

• Administer paracetamol (acetaminophen) immediately as first-line analgesia unless contraindicated 1, 2
• Add opioid analgesia cautiously for severe pain, with appropriate weight-based dosing for pediatric patients 4, 1
• Avoid NSAIDs until renal function is confirmed, as they are relatively contraindicated in patients with potential renal dysfunction 4, 1
• Consider femoral nerve block or fascia iliaca block for superior pain control, though these may not reliably block all three nerves (femoral, obturator, lateral cutaneous) 2

Immobilization

• Splint the fractured extremity immediately to reduce pain, prevent further soft tissue injury, and facilitate safe transport 2
• Treat the deformed fracture in the position found unless straightening is necessary to facilitate safe transport 2

Diagnostic Workup

Imaging Studies

• Obtain AP and lateral radiographs of the entire femur, including hip and knee joints 3
• Consider CT scan if fracture pattern is complex or involves the femoral neck, as this helps with surgical planning 5

Laboratory Studies

• Full blood count to assess for anemia from fracture-related hemorrhage 4
• Urea and electrolytes to evaluate renal function before administering NSAIDs or adjusting opioid dosing 4

Definitive Management

Surgical Planning

• Plan for early surgical fixation within 24 hours in hemodynamically stable patients, as this reduces local and systemic complications 2, 5
• Consult pediatric orthopedic surgery urgently, as proximal femur fractures in young children require specialized surgical expertise 6

Surgical Approach Considerations

• Intramedullary nailing or plate fixation are the primary surgical options, with the specific technique depending on fracture location and pattern 3, 5
• For femoral neck fractures, early anatomical reduction and surgical fixation remain the best option to reduce risk of complications like non-union and avascular necrosis 3
• Cancellous screws are preferred for fixation of neck femur fractures in younger populations 3

Critical Pitfalls to Avoid

• Do not delay pain assessment and management while focusing on other interventions; document pain scores before and after analgesia 1
• Do not prescribe NSAIDs without checking renal function first, as this population may have renal impairment 1
• Do not delay surgical fixation, as conservative management of displaced fractures leads to avascular necrosis and poor functional outcomes 7
• Do not treat displaced intracapsular fractures conservatively, as this significantly increases morbidity 7

Perioperative Considerations

Anesthesia

• Neuraxial blockade or general anesthesia with additional peripheral nerve blockade provides reliable surgical anesthesia and postoperative analgesia 7
• Ensure adequate postoperative analgesia, as inadequate pain control increases morbidity 7

Postoperative Care

• Continue regular paracetamol throughout the perioperative period 4
• Use opioids cautiously with reduced dose and frequency if renal dysfunction is present 4
• Avoid codeine, as it is constipating, emetic, and associated with cognitive dysfunction 4