This document provides a summary of 4 pediatric orthopedic imaging case studies involving femur fractures in patients aged 5 to 17 years old. It then reviews key anatomy, techniques for reading x-rays systematically, and classifications and management of pediatric femur fractures. The cases include femoral head, shaft, spiral and Salter-Harris fractures from injuries like gunshots, motor vehicle collisions and falls. The document emphasizes the importance of anatomy and assessing integrity of soft tissues and neurovascular status. Treatment options like casting or intramedullary nailing are discussed.

1. Pediatric Orthopedic Imaging Case Studies
Kelsey Lena, MD1, Danielle Sutton, MD1, Virginia Casey, MD2
Department of Emergency Medicine1 & OrthoCarolina2
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
Pediatric Orthopedic Imaging Mastery Project
October 2021

2. Disclosures
▪ This ongoing pediatric orthopedic imaging interpretation series is proudly
sponsored by the Emergency Medicine Residency Program at Carolinas
Medical Center
▪ The goal is to promote widespread imaging interpretation mastery.
▪ There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. It’s All About The Anatomy!

4. The Physics of X-Rays
• How far an X-ray projects depends on the density of tissue that is to be
penetrated
• If there is no tissue, the color of the x-ray will be black
• The greater the density, the lighter the color

5. Reading Systematically
• Identify you are reviewing the correct patients imaging
(name, date of birth, date of imaging)
• Review both AP and lateral views, as this can help you
describe the fracture/deformity in both planes
• X-rays of two adjacent joints must be taken or a joint
injury could potentially be missed
• Identify which bone and what fractured part of the bone is
injured
Diaphysis
Metaphysis
Epiphysis

6. CASE #1:
A 13-year-old male
presents to the Emergency
Department complaining of
right hip pain after being
shot while walking through
his neighborhood. Physical
examination reveals a
penetrating wound to his
right lateral thigh.
Diagnosis?
CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
duodenum

7. CASE #1:
A 13-year-old male
presents to the Emergency
Department complaining of
right hip pain after being
shot while walking through
his neighborhood. Physical
examination reveals a
penetrating wound to his
right lateral thigh.
Diagnosis?
Femoral Head Fracture
CBD
SMV
SMA
duodenum
Gallbladder
Pancreas with dilated duct
Portal vein
CBD and PD
duodenum
Note The Retained Bullet
Superior To The Linear
Fracture Of The Right
Acetabulum
Adjacent
Small
Fracture
Fragments

8. Here Is Another Example of A
Subsequent Femur Fracture
Secondary To A Gun Shot Wound
Minimally Displaced Fracture
Of The Distal Femur With
Retained Bullet Fragments
Within The Distal Thigh

9. Portal vein
CBD/PD
terminating
at duodenum
duodenum
Gallbladder
Hepatic
duct
CASE #2:
A 5-year-old female
presents to the Emergency
Department after being
involved in a motor vehicle
collision. On the trauma
survey, there is notable
swelling of the left thigh
compared to the right thigh
and the patient cries out in
pain when attempting to
palpate the region.
Diagnosis?

10. Portal vein
CBD/PD
terminating
at duodenum
duodenum
Gallbladder
Hepatic
duct
CASE #2:
A 5-year-old female
presents to the Emergency
Department after being
involved in a motor vehicle
collision. On the trauma
survey, there is notable
swelling of the left thigh
compared to the right thigh
and the patient cries out in
pain when attempting to
palpate the region.
Diagnosis?
Spiral Femur Fracture Mildly Displaced
Spiral Fracture With
No Angulation
After Cast Placement

11. Another Example Of A Spiral Femur
Fracture
Note The Comminuted
Spiral Fracture At The Mid-
Right Diaphysis With
Lateral Displacement Of
Distal Fracture Fragment

12. CASE #3:
A 6-year-old female presents
to the Emergency
Department after falling off
a playscape and landing on
her left leg, which already
has a cast in place after
fracturing her tibia 4 weeks
prior. The patient complains
of left thigh pain and there is
a notable closed deformity
with overlying edema
present.
Diagnosis?

13. CASE #3:
A 6-year-old female presents
to the Emergency
Department after falling off
a playscape and landing on
her left leg, which already
has a cast in place after
fracturing her tibia 4 weeks
prior. The patient complains
of left thigh pain and there is
a notable closed deformity
with overlying edema
present.
Diagnosis?
Mid-Shaft Femur Fracture
Note The Apex Lateral
Angulation
Overlapping Fracture
Fragments

14. CASE #4:
A 17-year-old female
presents to the
Emergency Department
after being involved in a
dirt bike accident. The
patient endorses
significant left lower
extremity pain with
inability to flex the knee
or raise the left leg
against gravity. There is
significant edema and
contusion formation of
the left thigh.
Diagnosis?

15. CASE #4:
A 17-year-old female
presents to the
Emergency Department
after being involved in a
dirt bike accident. The
patient endorses
significant left lower
extremity pain with
inability to flex the knee
or raise the left leg
against gravity. There is
significant edema and
contusion formation of
the left thigh.
Diagnosis?
Femoral Shaft
Fracture
Comminuted And
Mildly Overriding
Fracture

16. Medial Angulation
Of The Distal
Fracture Fragment
With
Foreshortening Of
The Femur
Comminuted And
Oblique Femur
Fracture
Another Example Of A
Mid-Shaft Femur Fracture

17. Another Comminuted Femur Fracture:
Lateral Butterfly Fragment
Slight Medial Displacement Of The Major
Distal Fragment

18. 6-Month-Old With A
History of Osteogenesis
Imperfecta
The Patient’s
Right Lower
Extremity Was
Bumped Against
The Car Door
While Family
Attempted To
Place Her In A
Car Seat
Transverse Fracture Of
The Right Femur

19. An Example Of A Distal Femur
Fracture:
Displaced Salter-Harris Type I
Fracture With Near Complete
Displacement Of The Distal
Fragment

20. Pediatric Femur Fractures
• 1-2% of all pediatric fractures
• Male predominance
• Bimodal distribution in age, occurring most often in patients 2-4 years
of age and in the adolescent stage
• Mechanism of injury:
< 10 years of age  Fall is the most common cause
> 10 years of age  MVC is the most common cause

21. Pediatric Femur Fractures: Classification
Transverse
Fracture
• Straight linear fracture across the shaft of the femur
• Depending on the clinical scenario, should raise the index of
suspicion for non-accidental trauma
Spiral
Fracture
• Fracture which encircles the shaft of the femur
• Secondary to a rotational or twisting force
• Resembles a corkscrew or winding staircase
Comminuted
Fracture
• Fracture where the bone has broken into three or more pieces
• Secondary to high-impact injury
Oblique
Fracture
• Fracture with angled line or break across the shaft of the femur
Include location of fracture (proximal, shaft, or distal third) and integrity of
soft tissue (open or closed fracture)

22. Pediatric Femur Fractures: Clinical Presentation
Physical
Exam
Ranges from edema and ecchymosis at the site of injury to gross deformity
with limited range of motion and/or shortening of the involved extremity
Neurologic
Assessment
Femoral Nerve
• Inability to flex the hip or extend the knee
• Absent sensation over the anteromedial thigh (anterior cutaneous nerve)
• Absent sensation over the medial leg and foot (saphenous nerve)
Vascular
Assessment
• Assess for warm, pink skin with capillary refill <2 seconds
• Ensure pulses are present with palpation or doppler signal
Femoral Artery
Closed femoral shaft fracture can hold up to 1,000-1,500 cc of blood

23. Pediatric Femur Fractures: Complications
Non-Union • Incomplete healing within 9 months of injury or no
evidence of healing on successive radiographs over 3
months
• Incidence < 10%
Limb Length
Discrepancy
• Leg length asymmetry secondary to disruption of the
physis
Compartment
Syndrome
• A potential complication of tight casts
• 6-P’s:
Pain, Paresthesia, Pallor, Poikilothermia,
Pulselessness, Paralysis
Monteggia Fracture
Non-Union

24. Pediatric Femur Fractures: Management
Long Leg Cast Or Hip Spica Cast
• Long leg cast stays in place for 4-6 weeks, with conversion to short walking cast
or walking cast boot until there is radiographic evidence of fracture union
• Hip spica cast used in patients < 5 years of age with length stable fractures, and
typically stays in place for 6 weeks – 3 months
Indications For Closed Reduction And Intramedullary Nailing:
• Gold standard for diaphyseal femur
fractures
• Severe open fractures
• Irreducible unstable fractures
(comminuted fractures)
• Ipsilateral femoral neck or acetabular
fracture
• Associated vascular injury
• Refracture injuries

25. orthobullets.com
Important Considerations
• Classification system to determine whether a
comminuted femoral shaft fracture requires
management with an intramedullary nail or open
reduction
• Types III and IV typically require open
reduction
orthobullets.com

26. Retrospective study which assessed
clinical and functional outcomes of
open vs. closed intramedullary
nailing for closed femoral shaft
fractures…
• Fixation of femoral shaft fractures
with open intramedullary nailing
has similar outcomes in time to
union compared to closed nailing
• Intraoperative blood loss was
greater in open intramedullary
nailing vs. closed nailing
• Superficial and deep infection
rates were similar in both
treatment groups

27. Summary of This
Month’s Diagnosis
• Femoral Shaft Fracture
• Transverse Femur Fracture
• Spiral Femur Fracture
• Oblique Femur Fracture
• Salter-Harris Femur Fracture

28. Resources
• Denisiuk M, Afsari A. Femoral Shaft Fractures. [Updated 2021 Jan 9]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2021 Jan
• Medda S, Unger T, Halvorson J. Diaphyseal Femur Fracture. [Updated 2021 Jul 19]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan
• Ostrum RF, Agarwal A, Lakatos R, Poka A. Prospective comparison of retrograde and antegrade
femoral intramedullary nailing. J Orthop Trauma. 2000 Sep-Oct;14(7):496-501. doi:
10.1097/00005131-200009000-00006. PMID: 11083612
• Stephen DJ, Kreder HJ, Schemitsch EH, Conlan LB, Wild L, McKee MD. Femoral intramedullary
nailing: comparison of fracture-table and manual traction. a prospective, randomized study. J Bone
Joint Surg Am. 2002 Sep;84(9):1514-21. doi: 10.2106/00004623-200209000-00002. PMID:
12208906
• Tahir M, Ahmed N, Faraz A, et al. (June 29, 2021) Comparison of Open and Closed Nailing for
Femoral Shaft Fractures: A Retrospective Analysis. Cureus 13(6): e16030. doi:10.7759/cureus.16030
• https://www.orthobullets.com/trauma/1040/femoral-shaft-fractures