Guideline sources The following summarized guidelines for the evaluation and management of pediatric femoral shaft fracture are prepared by our editorial team based on guidelines from the American Academy of Orthopaedic Surgeons (AAOS 2020; 2009) and the American College of Radiology (ACR 2019; 2018). 1 2 3 4 Guidelines 1. Diagnostic investigations Diagnostic imaging: As per ACR 2019 guidelines: Obtain hip and pelvic XR as the initial imaging of the hip with acute pain, fall or minor trauma, and suspected fracture. B Obtain MRI of pelvis and affected hip without IV contrast or CT of pelvis and hips without IV contrast as the next imaging study for the evaluation of acute hip pain from a fall or minor trauma with negative radiographs and suspected fracture. B As per ACR 2018 guidelines, obtain radiography of the tibia/fibula as the initial imaging in pediatric patients up to age 5 with acute limp, non-localized symptoms and no concern for infection. B Show 4 more https://web.pathway.md/diseases/recq6TVr7PhwQS7qd 1/3 6/29/23, 10:57 PM Pediatric femoral shaft fracture Pathway Evaluation for child abuse: evaluate pediatric patients < 36 months with a diaphyseal femur fracture for child abuse. A 2. Medical management Pain management: consider offering regional pain management for patient comfort perioperatively. C 3. Nonpharmacologic interventions Harness/casting: consider offering treatment with either a Pavlik harness or spica cast in pediatric patients 6 months of age with a diaphyseal femur fracture. C Show 2 more Physical therapy: insufficient evidence to recommend for or against outpatient physical therapy to improve function after treatment of pediatric diaphyseal femur fractures. I 4. Therapeutic procedures Nailing: Perform flexible intramedullary nailing for the treatment of pediatric patients 5-11 years of age with a d diaphyseal femur fracture. A Consider performing rigid trochanteric entry nailing, submuscular plating, or flexible intramedullary nailing as treatment options in pediatric patients aged 11 years to skeletal maturity. Do not perform piriformis or near piriformis entry rigid nailing. C Clinical findings Symptoms Social history Leg pain Child abuse Thigh pain Musculoskeletal exam Inability to walk Limping Shortened lower extremity Thigh deformity Thigh swelling References 1. AAOS. Treatment of Pediatric Diaphyseal Femur Fractures. AAOS. 5 Dec 2020. Open https://web.pathway.md/diseases/recq6TVr7PhwQS7qd 2/3 6/29/23, 10:57 PM Pediatric femoral shaft fracture Pathway 2. Expert Panel on Musculoskeletal Imaging, Andrew B Ross, Kenneth S Lee et al. ACR Appropriateness Criteria Acute Hip Pain-Suspected Fracture. J Am Coll Radiol. 2019 May;16 5S S18 S25. Open 3. Mininder S Kocher, Ernest L Sink, R Dale Blasier et al. Treatment of pediatric diaphyseal femur fractures. J Am Acad Orthop Surg. 2009 Nov;17 11 718 25. Open 4. Expert Panel on Pediatric Imaging, Nabile M Safdar, Cynthia K Rigsby et al. ACR Appropriateness Criteria Acutely Limping Child Up To Age 5. J Am Coll Radiol. 2018 Nov;15 11S S252 S262. Open https://web.pathway.md/diseases/recq6TVr7PhwQS7qd 3/3