Femur Fractures in Children: Treating a Child’s Broken Thighbone

What are the treatments for a broken femur in children?

As in an adult, the treatment goals for a child with a broken femur include achieving proper realignment of the bone, promoting rapid healing, and returning the patient to normal activities. However, there are also unique factors and considerations in the treatment of broken bones in children. These factors include:

• The configuration of the fracture. The most common patterns are:
  • Transverse fracture (straight across the shaft of the bone).
  • Oblique fracture (a fracture across the bone at an angle).
  • Spiral fracture (a longer fracture that usually spans a longer segment of the bone).
• The "energy" of the injury.
• The amount of soft tissue injury present.
• The patient’s size and age.
• The amount of growth the child has remaining.
• The potential for any shortening of the bone that can sometimes occur with a fracture of a growing bone.

How are femoral fractures in newborns and infants treated?

"At this young age, children’s bones heal very rapidly, usually by three to four weeks," says David M. Scher, MD, Attending Orthopedic Surgeon at Hospital for Special Surgery.

Unlike the healing process in adults, a certain amount of variation in alignment of the bone as it heals is acceptable in infants and older children, notes Dr. Scher. As the body lays down new bone, over time, there is an automatic "correction" or straightening during growth, called remodeling.

How are toddlers and young children treated for fractures of the femur?

Among children ranging from toddlers up to five, femur fractures usually result from a low energy fall, and a special type of cast called a spica cast is the most common treatment. In most cases, the orthopedic surgeon realigns the fracture using fluoroscopy or X-ray imaging as a guide and immobilizes the leg in the spica cast. This procedure usually takes place in the operating room and a pediatric anesthesiologist is present to administer a sedative or general anesthesia to keep the child comfortable.

Children remain in the spica cast for a period ranging from four to eight weeks, but sometimes as long as three months, which can be challenge for caregivers when it comes to maintaining hygiene and keeping the child distracted and happy. Though cumbersome, spica casting continues to be the continues to be the safest and least complicated method for treating fractures among this age group and yields excellent results.

(Click or tap the images to view in a larger size.)

Following treatment, the orthopedic surgeon continues to monitor the patient for a period of several years to ensure that there is no limb length discrepancy. "When a fracture in the shaft of the femur occurs, the bone tends to shorten at the point where it breaks, Dr. Scher explains. "Later on, as healing occurs among children in this age group, the bone tends to grow longer; this is a phenomenon called "overgrowth" that may be caused by increased blood flow to the fracture site."

In some patients this initial shortening, combined with the subsequent increased growth, "cancel" one another out. However, in those cases where a small limb length discrepancy occurs, the orthopedic surgeon can use a relatively simple technique, such as growth modulation of the longer leg, to address this issue.

Treatment for Children aged 5 to 10 years

Intramedullary nails come in a range of diameters to accommodate the varying size of children’s bones. "Generally no casting is necessary," Dr. Scher says, however a knee immobilizer is commonly used for a few weeks to prevent movement and to keep the child comfortable. In most cases, a recovery period of three to six weeks of early healing is necessary before the child can begin walking on the injured leg. When the bone is completely healed, usually around one year after the injury occurs, the child returns to the hospital to have the nails removed.

"Intramedullary nails are usually very well-tolerated," says Dr. Scher. "They are particularly useful in five- to ten-year-old children who have a thick lining around the bone called the periosteum, which might be likened to the peel on a banana. The periosteum helps keep the bone more stable and reduces the need for a heavy and rigid device, such as those that might be used in adults."

Treatment for older children and adolescents

Intramedullary nailing can also work well in older or heavier children, typically those over age 10 and heavier than 100 pounds. However, a single, thicker and more rigid nail is used rather than the smaller flexible nails.

Submuscular plating

Submuscular plating is another treatment option for older and larger children. In this procedure, using X-ray images for guidance, the orthopedic surgeon inserts a stainless-steel plate under the muscles of the leg and across the fracture site. Through small incisions in the skin, screws are placed through the plate and bone, above and below the fracture to hold it in place. Although this technique is minimally invasive, removal of the plate is more difficult than removal of intramedullary nails. "Currently, there is some discussion ongoing in the orthopedic community regarding the need to remove the plates at all," Dr. Scher says.

How has treatment for femoral fractures evolved?

The use of intramedullary nails, external fixators, and other stabilization devices represent a dramatic improvement over the traditional approach to fractures of the femur. As recently as the 1980s, the standard approach for most children over the age of two years was placement of a pin through the bone just above the knee and traction; this typically involved a hospital stay of three weeks or longer in which many adjustments were needed to maintain alignment. Traction was followed by placement in a body cast for as long as three months.

While this method resulted in excellent healing, proper alignment, and strong bones, it also required significant involvement on the part of a parent or other caregiver. "Fortunately, the available technology and our surgical skills have advanced to a point where we can achieve these same results in a more time-efficient manner which is much less disruptive to the family," says Dr. Scher. "Today we are able to make our treatment decisions based not only on how we can best get the fracture to heal, but also on choosing the method that will be best tolerated by the child and his or her family."

Learn more about the Pediatric Orthopedic Service at HSS.

Updated: 4/28/2022

Summary by Nancy Novick

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