Child Orthopedics

Frequently Asked Questions

We are missionaries living in a rural area of a small country with very few hospitals. Our nine-year-old daughter fell off a chair and broke her leg. We are trying to decide if this can be treated here or if we need to fly to a different country where the health care is more developed. She has a fracture of the shaft of the thigh bone. How would this be treated in the United States?

The type of leg fracture you are describing is called a pediatric dipahyseal femur fractures. Pediatric, of course, refers to children who are still growing. Diaphyseal tells us it's the shaft of a long bone and femur is the anatomical term for thigh bone. Even in the United States, children who suffer this type of fracture don't always have a specialized children's hospital to go to for the latest in care. Orthopedic surgeons around the country treating pediatric diaphyseal femur fractures aren't always pediatric specialists or if they are, they don't see 100s of these cases each year. So, even here, there can be wide ranges in the treatment approach for the same problem depending on where the treatment is administered and by whom. In order to help all orthopedic surgeons follow the best evidence in treating these traumatic injuries, the American Academy of Orthopaedic Surgeons (AAOS) has published this list of 14 clinical practice guidelines. They are specific to children from infancy to skeletal maturity who have broken the shaft of the femur. A group of 16 pediatric experts from around the country worked together to review all published studies from 1996 through 2008 just dealing with the treatment of diaphyseal femur fractures in children. In the course of reviewing treatment results and recommendations, they noticed a trend over the past 10 years. Treatment seems to have shifted away from conservative (nonoperative) care more toward surgical intervention to stabilize the leg. Nonsurgical options include Pavlik harness for infants, and traction or casting in a waist-high cast called a hip spica cast for all other ages. Surgery can include placing a nail (long metal rod) down through the bone, and/or special submuscular plating. Different types of nails can be used. Some are rigid, others are more flexible. Pain management may be required no matter what type of treatment is used. The specific treatment plan selected depends on many factors such as the child's age, type of fracture (severity, location, displaced versus nondisplaced), and the family's social and economic situation. One other thing to consider in your situation is the need for follow-up during the months of healing and recovery. Repeated X-rays will be needed to check the progress of the fracture. It's important to watch for any shifts in the fracture site that could result in a shortening or lengthening of the bone and eventual leg length difference. Once you visit with the local hospital staff and see the X-rays, the decision about specific treatment and location of treatment may become much clearer. If your child needs extended hospitalization for traction or a spica cast, it might change how you decide what's best. Caring for a nine-year-old in a spica cast has some additional challenges you'll want to consider.

Mininder S. Kocher, MD, MPH, et al. Treatment of Pediatric Diaphyseal Femur Fractures. In Journal of the American Academy of Orthopaedic Surgeons. November 2009. Vol. 17. No. 11. Pp. 718-725.

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