Distal femoral fractures in children
- Kimberly P Stone, MD, MS, MA
Kimberly P Stone, MD, MS, MA
- Associate Professor of Pediatrics
- University of Washington
- Klane White, MD
Klane White, MD
- Associate Professor, Department of Orthopaedics and Sports Medicine
- University of Washington School of Medicine
- Section Editor
- Susan B Torrey, MD
Susan B Torrey, MD
- Section Editor — Pediatric Resuscitation; Pediatric Trauma
- Director, Division of Pediatric Emergency Medicine
- Associate Professor of Emergency Medicine and Pediatrics (Clinical)
- NYU School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Distal femur fractures in pediatrics patients are discussed here. Hip fractures and femoral shaft fractures in children are discussed separately. (See "Hip fractures in children" and "Femoral shaft fractures in children".)
Distal femur fractures can be classified as metaphyseal fractures or physeal fractures.
Metaphyseal fractures — Transverse distal metaphyseal fractures (also called supracondylar femoral fractures) are the most common type of distal femur fracture in infants and young children (image 1) .
Physeal fractures — Distal physeal femur fractures occur more commonly in older children and adolescents. The Salter-Harris classification of physeal fractures is most often used (figure 1).
●Salter-Harris type I – Salter-Harris type I fractures were thought to be an uncommon type of distal pediatric femur fracture in early studies, accounting for only about 7 percent of distal femur physeal fractures . However, more recent studies suggest an incidence of between 21 to 25 percent [3-5]. Salter-Harris Type I fractures occur in vaginally delivered breech newborns, abused infants, and as a sports related injury in adolescents [6,7]. When there is no fracture displacement, initial plain radiographs may be negative which can make these injuries difficult to diagnose. (See 'Imaging' below.)
- Smith NC, Parker D, McNicol D. Supracondylar fractures of the femur in children. J Pediatr Orthop 2001; 21:600.
- Lombardo SJ, Harvey JP Jr. Fractures of the distal femoral epiphyses. Factors influencing prognosis: a review of thirty-four cases. J Bone Joint Surg Am 1977; 59:742.
- Arkader A, Warner WC Jr, Horn BD, et al. Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop 2007; 27:703.
- Eid AM, Hafez MA. Traumatic injuries of the distal femoral physis. Retrospective study on 151 cases. Injury 2002; 33:251.
- Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0-16 years. J Pediatr Orthop 1990; 10:713.
- Herring JA. Tachdijan's Pediatric Orthopadeics, 4th, Saunders, Philadelphia 2007.
- Price CT, Herrera-Soto J. Extra-articular injuries of the knee. In: Rockwood and Wilkins' Fractures in Children, 7th edition, Beaty JH, Kasser JR. (Eds), Lippincott, Williams & Wilkins, Philadelphia 2010. p.842.
- Thomson JD, Stricker SJ, Williams MM. Fractures of the distal femoral epiphyseal plate. J Pediatr Orthop 1995; 15:474.
- Bertin KC, Goble EM. Ligament injuries associated with physeal fractures about the knee. Clin Orthop Relat Res 1983; :188.
- Ilharreborde B, Raquillet C, Morel E, et al. Long-term prognosis of Salter-Harris type 2 injuries of the distal femoral physis. J Pediatr Orthop B 2006; 15:433.
- Rewers A, Hedegaard H, Lezotte D, et al. Childhood femur fractures, associated injuries, and sociodemographic risk factors: a population-based study. Pediatrics 2005; 115:e543.
- Loder RT, O'Donnell PW, Feinberg JR. Epidemiology and mechanisms of femur fractures in children. J Pediatr Orthop 2006; 26:561.
- Peterson CA, Peterson HA. Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma 1972; 12:275.
- Lippert WC, Owens RF, Wall EJ. Salter-Harris type III fractures of the distal femur: plain radiographs can be deceptive. J Pediatr Orthop 2010; 30:598.
- Beaty JH, Kumar A. Fractures about the knee in children. J Bone Joint Surg Am 1994; 76:1870.
- Brone LA, Wroble RR. Salter-Harris type III fracture of the medial femoral condyle associated with an anterior cruciate ligament tear. Report of three cases and review of the literature. Am J Sports Med 1998; 26:581.
- Arkader A, Friedman JE, Warner WC Jr, Wells L. Complete distal femoral metaphyseal fractures: a harbinger of child abuse before walking age. J Pediatr Orthop 2007; 27:751.
- Nicandri GT, Dunbar RP, Wahl CJ. Are evidence-based protocols which identify vascular injury associated with knee dislocation underutilized? Knee Surg Sports Traumatol Arthrosc 2010; 18:1005.
- Wathen JE, Gao D, Merritt G, et al. A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Ann Emerg Med 2007; 50:162.
- Neubrand TL, Roswell K, Deakyne S, et al. Fascia iliaca compartment nerve block versus systemic pain control for acute femur fractures in the pediatric emergency department. Pediatr Emerg Care 2014; 30:469.
- Turner AL, Stevenson MD, Cross KP. Impact of ultrasound-guided femoral nerve blocks in the pediatric emergency department. Pediatr Emerg Care 2014; 30:227.
- Aronson J, Tursky EA. External fixation of femur fractures in children. J Pediatr Orthop 1992; 12:157.
- Poolman RW, Kocher MS, Bhandari M. Pediatric femoral fractures: a systematic review of 2422 cases. J Orthop Trauma 2006; 20:648.
- Flynn JM, Hresko T, Reynolds RA, et al. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop 2001; 21:4.
- Ferguson J, Nicol RO. Early spica treatment of pediatric femoral shaft fractures. J Pediatr Orthop 2000; 20:189.
- Kluger Y, Gonze MD, Paul DB, et al. Blunt vascular injury associated with closed mid-shaft femur fracture: a plea for concern. J Trauma 1994; 36:222.
- Canale ST, Puhl J, Watson FM, Gillespie R. Acute osteomyelitis following closed fractures. Report of three cases. J Bone Joint Surg Am 1975; 57:415.
- Basener CJ, Mehlman CT, DiPasquale TG. Growth disturbance after distal femoral growth plate fractures in children: a meta-analysis. J Orthop Trauma 2009; 23:663.
- Davids JR. Rotational deformity and remodeling after fracture of the femur in children. Clin Orthop Relat Res 1994; :27.
- Wallace ME, Hoffman EB. Remodelling of angular deformity after femoral shaft fractures in children. J Bone Joint Surg Br 1992; 74:765.
- Staheli LT. Femoral and tibial growth following femoral shaft fracture in childhood. Clin Orthop Relat Res 1967; 55:159.
- Herring JA, Tachdijan S. Pediatric Orthopedics from the Texas Scottish Rite Hospital for Children, 4th, Saunders Elsevier, Philadelphia 2008. Vol 3.
- Staheli LT. Leg lenth inequality. In: Practice of Pediatric Orthopedics, Staheli LT. (Ed), Lippincott, Williams & Wilkins, Philadelphia 2006. p.96.
- Metaphyseal fractures
- Physeal fractures
- CLINICAL ANATOMY
- MECHANISM OF INJURY
- CLINICAL FEATURES AND EXAMINATION
- Plain radiographs
- Other imaging
- INITIAL TREATMENT
- Child protection
- INDICATIONS FOR ORTHOPEDIC CONSULT OR REFERRAL
- DEFINITIVE CARE
- FOLLOW-UP CARE
- RETURN TO SPORT OR WORK
- SUMMARY AND RECOMMENDATIONS