Pediatric femoral shaft fractures: a system for decision making

Pediatric femoral shaft fractures are one of the most common major pediatric injuries treated by orthopaedic surgeons. Historically, casting, with or without traction, was the standard of care for almost all pediatric femoral fractures. However, during the past 15 years, there has been a trend toward surgical fixation and rapid mobilization. This evolution has given orthopaedic surgeons many treatment methods in which they must consider patient age and size, fracture pattern, and the surgeon's own skills and experience. The evolution away from casting, with or without traction, has led to seven treatment options: (1) a Pavlik harness with or without a splint, (2) a walking spica cast, (3) a standard spica cast with or without traction, (4) elastic intramedullary nailing, (5) submuscular plating, (6) external fixation, or (7) trochanteric-entry intramedullary nailing. To determine which treatment option is best for a specific fracture type in a specific patient, pediatric femoral shaft fractures can be divided into five classes: (1) fractures that will heal with limited intervention; (2) fractures that should be treated without surgery, but must be watched closely; (3) fractures that benefit from surgical intervention with load-sharing implants; (4) fractures that may benefit from surgical intervention with rigid fixation; and (5) fractures in a patient with a limb at risk and associated injuries that require initial treatment precedence.