Your team of physicians will be trying to find the best way to stabilize the femoral fracture while minimizing pain, maximizing comfort, and preventing scarring or complications. The two basic treatment options are: conservative (nonoperative) care with the cast you mentioned and surgery. The operation is designed to apply some type of hardware to help hold the broken pieces together while the bone heals. This process is referred to as surgical fixation.
But before we fill you in on the surgical side of femoral fracture fixation, let’s take a quick look at nonoperative management. Cast immobilization is a possibility for some children. The cast goes from hip to toes and is called a spica or hip spica cast. Conservative care of this type is possible when the patient is a young child or a small child (up to 60 pounds).
The benefits of this type of treatment include no surgery, very short time in the hospital, avoiding scars from surgical incisions, and preventing infection. The downside of cast immobilization includes the child has to wear a hot, bulky cast and you as the parents have to care for the child who can’t bend at the waist, roll over, use a toilet, or walk.
There is also the possibility that the fracture will heal improperly when only held in place by a cast. The fracture might separate, a process called “loss of reduction.” Or the broken bones could shift the other way, overlapping each other causing shortening of the leg. But, if it doesn’t work, the child could always still have surgery.
Now let’s consider the pros and cons of surgical fixation. There are two common choices here as well: elastic stable intramedullary nailing and locked intramedullary nails. Elastic, slightly flexible long nails have been the most popular choice for the last 20 years. Titanium has replaced stainless steel making it possible to have a narrow, lighter, less rigid rod down the center of the bone. The child does not have to be in a cast or brace and that is a big advantage. The flexibility of the nail(s) makes it possible for the fracture to withstand some load or force without losing stabilization.
There is some debate about whether or not the nails should be removed after the fracture has healed fully. Pulling the nails back out means another set of small incisions. Sometimes the nail doesn’t come out easily or breaks in the process. That can add another dimension of complexity. While the nails are in place, there can be some irritation and pain at the site where the nail was inserted.
The more rigid locked intramedullary nails are used for adults but also work well for older children/teens or heavier children. They are also the best choice when the fracture site is broken into many little pieces of bone or unstable for any other reason. This type of fixation does not have to be removed.
The surgeon will weigh all of the pros and cons of each approach and evaluate each child individually when deciding what is best. Factors that must be taken into consideration include the child’s age, weight and size, and type and severity of fracture. The surgeon’s own level of experience and expertise will make a difference along with any other injuries (especially soft tissue trauma) affecting the leg.