straightening the spiral…

the case.

a 2 year old male is carried into your ED screaming. He is horribly distressed and trying to reach down to grab at his right thigh. His parents report that he was standing outside watching his older brother ride his bike. He was knocked over in the process and his right leg ‘twisted around’ in the process.

On assessment,

• ABC & D are all ok.
• He is screaming and can’t be settled.
• His right thigh is swollen and tender. Good dorsalis pedis pulse. Brisk cap refill.
• He has obviously broken his femur.

Here is his first x-ray…

** Spiral mid-shaft femoral shaft fracture **

Despite a generous dose of intranasal fentanyl and comfort from Mum, he still attempts to flex his knee and hip, trying to grab the obviously painful thigh….

[DDET How are you going to manage this case ?]

What did we do ?

• IV access
• Ketamine (1mg/kg IV).
• Once dissociated, long-leg back slab placed.
• Plan for traction to follow.

Disclaimer: it takes quite a while to facilitate traction in our ED. Bed & equipment must be bought from the Orthopaedic ward.

[/DDET]

[DDET How did things look after ?]

Follow-up xrays…

   

Not entirely perfect, however it prevented further voluntary movement of the injured leg (& subsequent muscle spasm). It led to a marked improvement in patient comfort.

Shortly after, we simply applied traction to the cast whilst awaiting admission under Orthopaedics.

[/DDET]

[DDET What else should we consider in these injuries ?]

Pediatric Femoral Shaft Fracture.

Further Assessment.

• Neurovascular status.
  • Vascular injuries are rare, but you don’t want to miss one.
• Consideration of child safety !!
  • Strongly suspect NAI in patient < 5 years of age with femoral shaft fractures.
    • Especially in children who are not yet walking.
  • Incidence: ≥ 50% of infants and young children who sustain femur fractures are victims of child abuse.
  • Femoral fracture is 2nd most common NAI-associated fracture (following humeral fracture).
  • Does the reported mechanism of injury fit the injury ??
  • Is the story consistent between staff & amongst family members ??
• Hypotension.
  • Rarely results from isolated paediatric femur #’s
  • If present –> promptly search for other injuries…

Femoral Nerve Block.

• We should probably be better at this…
  • Unnecessary delays to initiating the procedure are the norm.
  • Often ‘non-ED’ staff relied upon to perform the block.
• Evidence suggests;
  • FMB provides more superior pain management compared to intravenous morphine at both 30 minutes & throughout initial 6 hours of treatment.
  • Ultrasound guidance increases duration of block and requires smaller volumes of anaesthetic.
• Check your drug doses !!!
  • Smaller weights, increased likelihood of toxicity.
  • Anaesthetists tend to give more drug (likely due to increased confidence in dosing).
• There is a nice discussion at St Emlyn’s by Natalie May covering this topic.
  • Do you mix ?? ie. Lignocaine with bupivicaine or just bupivicaine straight-up ??
  • I like the suggestion of early application of local anaesthetic gel to the ipsilateral groin (in preemption of performing the FNB).

Below is a video by Al Sacchetti demonstrating a fascia iliaca block for paediatric femur fractures.

httpv://www.youtube.com/watch?v=w0SkxMRyZfM

[/DDET]

[DDET More on management…]

Management.

• ABCDE (especially if associated with poly-trauma).
• Analgesia.
  • Multi-modal.
  • Utilise intranasal techniques upfront.
  • Intravenous opiates.
  • Don’t forget femoral nerve blocks.
  • Immobilise !! (Splint, traction etc).
• Ongoing neurovascular (re)assessment.
• Definitive management is dependent upon age, severity of fracture and associated injuries (see table below).
  • Important to acknowledge that whilst most of these are managed ‘non-operatively’ the application of Spica casts & harnesses more often than not require sedation (or anaesthesia).

* Pelvic Spica splint *

* Pavlik Harness *

[/DDET]

[DDET References.]

1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
2. Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition.
3. Greene WB. Displaced fractures of the femoral shaft in children. Unique features and therapeutic options. Clin Orthop Relat Res. Aug 1998;86-96. [Medline].
4. Chu RS, et al. Femoral nerve block for femoral shaft fractures in a paediatric Emergency Department: can it be done better? Eur J Emerg Med. 2003 Dec;10(4):258-63.
5. Frenkel O, Mansour K, Fischer JW. Ultrasound-guided femoral nerve block for pain control in an infant with a femur fracture due to nonaccidental trauma. Pediatr Emerg Care. 2012 Feb;28(2):183-4.
6. Oberndorfer A, et al. Ultrasonographic guidance for sciatic and femoral nerve blocks in children. British Journal of Anaesthesia. 98 (6): 797–801
7. Moores, A & Fairgrieve. Regional anaesthesia in paediatric practice. Current Anaesthesia & Critical Care (2004) 15, 284–293.
8. http://www.wheelessonline.com/ortho/pediatric_femur_fractures
9. http://www.orthobullets.com/pediatrics/4019/femur-fractures–pediatric
10. http://emedicine.medscape.com/article/1246915-overview#aw2aab6b9

[/DDET]