Femoral shaft fractures in young children (<5 years of age): operative and non-operative treatments in clinical practice

Femoral shaft fractures comprise around 4 % of all long-bone fractures in childhood. There is controversy about the treatment of fractures in children below 5 years, between those preferring non-operative methods, such as casting or traction, and those supporting elastic stable intramedullary nailing (ESIN). This retrospective study evaluates the day-by-day treatment of femoral shaft fractures in children aged 6-60 months in four major paediatric surgery trauma centres in Germany from 1 January 2004 to 31 December 2011 by chart review. We analysed all patient-related data, causes of fracture, fracture type, treatment method and potential post-treatment complications. We identified 225 patients (male to female 2:1) with femoral shaft fractures. Around 2/3 of these resulted from falls of less than 1 m or 1-3 m, the most frequent result (> 40 %) being a long spiral fracture. All 19 children below 1 year of age were treated by casting or traction. Between the ages of 12 and 24 months (n = 56), different treatment concepts were preferred (1/5 ESIN, 2/5 traction and 2/5 spica casting). Between 24 and 36 months, operative and non-operative therapies were equally distributed. In children older than 36 months (n = 64), most fractures were treated by ESIN: six children by external fixation and 14 by other treatments like spica casting, plate osteosynthesis or a combination of methods. 42 changes of treatment were performed: traction to spica casting or secondary operative treatment and 21 complications occurred (nails left in place for too long, skin defects or wound infections). Spica casting of femoral shaft fractures or, in some cases, traction is still the preferred treatment in the first and second years of life. In the third year, children are treated operatively as well as non-operatively, although now there is no current evidence of better short-term outcomes in operatively treated children. But elastic stable intramedullary nailing is the standard treatment for femoral shaft fractures in children older than 3 years of age.