Femur Fractures in Children - Case Presentation

8/11/2019 Femur Fractures in Children - Case Presentation

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ISOLATED FEMUR

SHAFT FRACTURES INPAEDIATRICS

Management & NursingCare

Christian Micallef


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Main Aims

To get a better understanding of:Femur Fractures in Children

Management of fractures in the EDUse and Application of Femur Traction DevicesNursing care of the child with a femur shaft

fracture


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Classification and DefinitionFractures of the femur are categorized by the exact location of the break:

Proximal femoral fractures - Proximal femur fractures, also called hipfractures , involve the upper-most portion of the thigh bone, just adjacent tothe hip joint. These fractures are further subdivided into different types of hipfractures 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 generallyoccurs in high-speed motor car accidents or falls from a height.

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

http://orthoanswer.org (Accessed on 26th Dec 2013)
http://orthoanswer.org/hip/hip-fractures/definition.htmlhttp://orthoanswer.org/hip/hip-fractures/definition.htmlhttp://orthoanswer.org/http://orthoanswer.org/http://orthoanswer.org/hip/hip-fractures/definition.htmlhttp://orthoanswer.org/hip/hip-fractures/definition.html


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Femur Shaft Fractures in Paediatrics

Special Considerations:NAI Child abuse occurs in 50-80% of children


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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? Otherunderlying conditions (e.g. OsteogenesisImperfecta, Osteoporosis)


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Case Presentation

Joey, a two year old boy presented to theemergency department, accompanied by hisparents, after slipping on a TV remote andlanding awkwardly onto his left leg..Crying and unsettled since the incident, with apainful left thigh..


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The Nursing Process

APIE - created by Ida Jean Orlando (1958) The Modified Nursing Process:

AssessmentDiagnosisPlanImplementationEvaluation


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Assessment

Triage use of structured approach (ALSG,2011)

ABC normalD unable to bear own weight onto left legE Pain (Severe) to left thigh area, swelling

noted, shortening and external rotation of leftleg no analgesia given prior to attendanceF Both parents in attendance


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Diagnosis

Nursing Diagnosis Possible fracture to the leftfemur


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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 referralNursing Care and Discharge Planning


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Intervention

Analgesia IV access Morphine 0.1mg/kg andParacetamol 15mg/kg given + ENTONOX prnX-Ray (portable) fracture of the left femur shaft

Reduction & Immobilization of the left Femurusing a Thomas Femur Traction Splint + repeat X-RayReview by orthopaedic surgeons surgery notrequired at the time PLAN: admission and fastingovernight, for reduction and application of hip spicaunder vision in O.T.


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History of Splinting

Ancient Egypt: wooden splints made of bark wrappedin linen

Ancient Hindus: treatment of fractures with bamboo

splintsHippocrates: writings on management of fractures - wooden splints plus exercise to prevent muscle atrophyduring the immobilization

Ancient Greeks, Romans and Arabian doctors useddifferent techniques and materials to immobilizefractures


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Femur Traction SplintsHISTORY:1875 Hugh Owen Thomas (Welsh bonesetter) devised the first practical traction splint

offered to French army (Franco-Prussian War) not used until WW I1915 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 splint1960s Glenn Hare (ambulance attendant/policeman) Hare Traction Splint

ratcheted cylinder that winds up a strap attached to an ankle hitch1972 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 lateralaspect of leg traction obtained by pulling on a strap

Latest Faretec CT-6 similar to KTD carbon fiber rod instead of aluminium cordthrough a ratcheted pulleyDr. Sam Slishman Adjustable Support Slishman Splint Lateral aspect of leg -does not extend past the foot easier for helicopter transfers

Donelan (2002)


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Thomas SplintHalf Ring Splint

Hare Splint

Kendrick Splint

Slishman SplintFaretec CT-6Sager Splint


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Application of a Thomas Femur Traction Splint

Additional Analgesia ENTONOX +/- FemoralNerve Block (ultrasound assisted)Explain Procedure to Parents and ChildGather EquipmentRepeat X-RayPre- and Post-Traction Circulatory Checks (colour,sensation, pedal pulses, warmth & movement)ONLY use in isolated femur shaft fractures


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Nursing Care

Comfort/Pain Assessment and AnalgesiaLimb Elevation

Circulatory Observations colour, sensation, warmth and movementUseful tips

Mark sites of pedal pulsesO2 sats probe to toe of affected limb


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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 givenSpecialists were consulted as required and the mostappropriate care/treatment provided

Analgesia was offered several times and administered as

requiredNursing handover when transferred to ward


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Re-Evaluation

Use of different SplintsUltrasound Assisted Femoral Nerve Block

a safe and easy procedure that can be performed with minimalu.s. training in the ED for femoral fractures. The 3-in-1 FNBprovides rapid, effective anaesthesia and has also been shown todecrease the opioid and volume of local anaesthetic requirementfor pain management (Christos et al., 2010)

Set Guidelines


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Current Treatment

Infants (up to 18months) Gallows(


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References Advanced Life Support Group, ALSG (2011) Paediatric Advanced Life Support The Practical Approach 5th Edition . West Sussex: Wiley-BlackwellChristos 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 bythe American Safety & Health Institute Available at www.wildernessemergencycare.com (Accessed on 26th Dec2013)

Galano G.J., Vitale M.A., Kessler M.W. (2005) The most frequent traumatic orthopaedic injuries from a nationalpaediatric 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, mechanismsand 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 26th Dec 2013)

Rewers A., Hedegaard H., Lezotte D. (2005) Childhood femur fractures, associated injuries and sociodemographicrisk factors: a population-based study. Pediatrics 2005; 115:e543Stone K.P. and White K. (2012) Femoral Shaft Fractures in Children. Available at www.uptodate.com (Accessed

on 27th Dec 2013)

Wheeless C.R. (2012) Femoral Fractures. Available at www.wheelessonline.com (Accessed on 27th Dec 2013)
http://www.wildernessemergencycare.com/http://orthoanswer.org/http://www.uptodate.com/http://www.wheelessonline.com/http://www.wheelessonline.com/http://www.uptodate.com/http://orthoanswer.org/http://www.wildernessemergencycare.com/


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Thank you

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Femur Fractures in Children - Case Presentation

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