ISOLATED FEMUR

SHAFT FRACTURES IN
PAEDIATRICS

Management & Nursing
Care





Christian Micallef
Main Aims
To get a better understanding of:
Femur Fractures in Children
Management of fractures in the ED
Use and Application of Femur Traction Devices
Nursing care of the child with a femur shaft
fracture
Classification and Definition
Fractures of the femur are categorized by the exact location of the break:

Proximal femoral fractures - Proximal femur fractures, also called hip
fractures, involve the upper-most portion of the thigh bone, just adjacent to
the hip joint. These fractures are further subdivided into different types of hip
fractures that have a bearing on how a surgeon may choose to fix the fracture.

Shaft fractures - A femoral shaft fracture is a severe injury that generally
occurs in high-speed motor car accidents or falls from a height.

Distal femoral fractures - Also called a supracondylar femur fracture, is an
injury to the thigh bone just above the knee joint. These fractures can involve
the cartilage surface of the knee joint, which put you at risk of developing
knee arthritis later in life.

http://orthoanswer.org (Accessed on 26
th
Dec 2013)
Femur Shaft Fractures in Paediatrics
Special Considerations:

NAI Child abuse occurs in 50-80% of children <2years and in up to 30%
of children <4years with femoral fractures (Wheeless, 2012)

Femoral shaft fractures are among the most common diaphyseal fractures in
children with an estimated annual incidence of 19 fractures per 100,000
children in the United States (Hunter, 2005; Loder et al, 2006; Rewers et al,
2005 and Hinton et al, 1999). They are also the most common pediatric
fracture of the femur, accounting for up to 62 percent of all femur fractures
(Rewers et al, 2005).

Several observational studies have identified a bimodal age distribution for
femoral shaft fractures with peaks in the toddler age group, where falls are the
predominant cause of injury, and in the adolescent age group, where motor
vehicle collisions cause most of the fractures (Loder et al, 2006; Rewers et al,
2005; Hinton et al, 1999; Galano et al, 2005). Across all age groups, boys
have higher rates of femoral shaft fractures than girls (Stone and White, 2012)
Special Considerationscont..
Is the child stable? (AcBC resus?)
Is it an isolated injury or part of a multi-
trauma?
Is it Organic in nature? Tumour? Other
underlying conditions (e.g. Osteogenesis
Imperfecta, Osteoporosis)


Case Presentation
Joey, a two year old boy presented to the
emergency department, accompanied by his
parents, after slipping on a TV remote and
landing awkwardly onto his left leg..
Crying and unsettled since the incident, with a
painful left thigh..
The Nursing Process
APIE - created by Ida Jean Orlando (1958)
The Modified Nursing Process:
Assessment
Diagnosis
Plan
Implementation
Evaluation

Assessment
Triage use of structured approach (ALSG,
2011)
ABC normal
D unable to bear own weight onto left leg
E Pain (Severe) to left thigh area, swelling
noted, shortening and external rotation of left
leg no analgesia given prior to attendance
F Both parents in attendance
Diagnosis
Nursing Diagnosis Possible fracture to the left
femur
Plan
Comfort Pain Management
Triaged at Category 2 Transferred to Resus
Seen by one of the ED Consultants:
Possible fractured femur (for portable X-Ray)
If fractured, provide treatment as required
Ortho referral
Nursing Care and Discharge Planning

Intervention
Analgesia IV access Morphine 0.1mg/kg and
Paracetamol 15mg/kg given + ENTONOX prn
X-Ray (portable) fracture of the left femur shaft
Reduction & Immobilization of the left Femur
using a Thomas Femur Traction Splint + repeat X-
Ray
Review by orthopaedic surgeons surgery not
required at the time PLAN: admission and fasting
overnight, for reduction and application of hip spica
under vision in O.T.

History of Splinting
Ancient Egypt: wooden splints made of bark wrapped
in linen
Ancient Hindus: treatment of fractures with bamboo
splints
Hippocrates: writings on management of fractures -
wooden splints plus exercise to prevent muscle atrophy
during the immobilization
Ancient Greeks, Romans and Arabian doctors used
different techniques and materials to immobilize
fractures
Femur Traction Splints
HISTORY:
1875 Hugh Owen Thomas (Welsh bonesetter) devised the first practical traction splint
offered to French army (Franco-Prussian War) not used until WW I
1915 Sir Robert Jones Thomas Leg Splint 1918 used by British & French armies
reduced mortality in military femur fractures from 80% to about 7%
Keller-Blake changed from ring to hinged half-ring splint
1960s Glenn Hare (ambulance attendant/policeman) Hare Traction Splint
ratcheted cylinder that winds up a strap attached to an ankle hitch
1972 Joseph Sager & Dr. A. Borschneck devised the Sager splint pad between legs,
rod to medial aspect of the leg
1986 Richard Kendrick devised the Kendrick Traction Device (KTD) rod to lateral
aspect of leg traction obtained by pulling on a strap
Latest Faretec CT-6 similar to KTD carbon fiber rod instead of aluminium cord
through a ratcheted pulley
Dr. Sam Slishman Adjustable Support Slishman Splint Lateral aspect of leg -
does not extend past the foot easier for helicopter transfers
Donelan (2002)



Thomas Splint
Half Ring Splint
Hare Splint
Kendrick Splint
Slishman Splint
Faretec CT-6
Sager Splint
Application of a Thomas Femur
Traction Splint

Additional Analgesia ENTONOX +/- Femoral
Nerve Block (ultrasound assisted)
Explain Procedure to Parents and Child
Gather Equipment
Repeat X-Ray
Pre- and Post-Traction Circulatory Checks (colour,
sensation, pedal pulses, warmth & movement)
ONLY use in isolated femur shaft fractures


Thomas Splint
PRACTICE

REMEMBER:

inner, under, outer, over
Nursing Care
Comfort/Pain Assessment and Analgesia
Limb Elevation
Circulatory Observations colour, sensation,
warmth and movement
Useful tips
Mark sites of pedal pulses
O
2
sats probe to toe of affected limb
Evaluation
Time elapsed between registration and transfer to ward
was approx. 2hours
Adequate communication with Joey and his parents -
step by step explanation of the care plan was given
Specialists were consulted as required and the most
appropriate care/treatment provided
Analgesia was offered several times and administered as
required
Nursing handover when transferred to ward
Re-Evaluation
Use of different Splints
Ultrasound Assisted Femoral Nerve Block
a safe and easy procedure that can be performed with minimal
u.s. training in the ED for femoral fractures. The 3-in-1 FNB
provides rapid, effective anaesthesia and has also been shown to
decrease the opioid and volume of local anaesthetic requirement
for pain management (Christos et al., 2010)
Set Guidelines
Current Treatment
Infants (up to 18months) Gallows
(<12months, limit 16-18kg) or Hip Spica
Toddlers (18months to 4 years) Skin Traction
(Hamilton-Russell) or Hip Spica
4 to 12 years Traction, Hip Spica,
Intramedullary Nail, External Fixation or Plate
Fixation
12 years and over - Skeletal Traction, Plate
Fixation, Intramedullary Nailing or External
Fixation
Wheeless (2012)
References
Advanced Life Support Group, ALSG (2011) Paediatric Advanced Life Support The Practical Approach 5th Edition.
West Sussex: Wiley-Blackwell

Christos S.C, Chiampas G., Offman R., Rifenburg R. (2010) Ultrasound-Guided Three-in-One Nerve Block for
Femur Fractures. West Journal Of Emergency Medicine 2010 September, 11(4): 310-313

Donelan S. (2002) Splinting Fractured Femurs: Then and now. Wilderness Emergency Care Book, published by
the American Safety & Health Institute Available at www.wildernessemergencycare.com (Accessed on 26
th
Dec
2013)

Galano G.J., Vitale M.A., Kessler M.W. (2005) The most frequent traumatic orthopaedic injuries from a national
paediatric inpatient population. Journal of Paediatric Orthopaedics 2005; 25:39

Hinton R.Y., Lincoln A., Crockett M.M. (1999) Fractures of the femoral shaft in children Incidence, mechanisms
and sociodemographic risk factors. Journal of Bone and Joint Surgery American Volume 1999; 81:500

Hunter J.B. (2005) Femoral Shaft Fractures in Children. Injury 2005; 36 Suppl 1:A86

Loder R.T., ODonnell P.W., Feinberg J.R. (2006) Epidemiology and mechanisms of femur fractures in children.
Journal of Paediatric Orthopaedics 2006; 26:561

Orthoanswer (2013) Femur Fractures. Available at http://orthoanswer.org (Accessed on 26
th
Dec 2013)

Rewers A., Hedegaard H., Lezotte D. (2005) Childhood femur fractures, associated injuries and sociodemographic
risk factors: a population-based study. Pediatrics 2005; 115:e543
Stone K.P. and White K. (2012) Femoral Shaft Fractures in Children. Available at www.uptodate.com (Accessed
on 27
th
Dec 2013)

Wheeless C.R. (2012) Femoral Fractures. Available at www.wheelessonline.com (Accessed on 27
th
Dec 2013)

Thank you


Any Questions?