SEPTEMBER 2012 | Volume 35 • Number 9 773

n tips & techniquesSection Editor: Steven F. Harwin, MD

Femur fractures are com-mon injuries, accounting

for 1.6% of all fractures in children and affecting 19 in 100,000 children annually in the United States.1 Two peaks occur in the incidence of these fractures in children, with the first peak in toddlers af-ter a fall and the second peak in adolescents after a high- energy trauma.2 Pediatric fe-

mur fracture is the most com-mon orthopedic diagnosis among pediatric trauma pa-tients admitted to hospitals.1

Acute management and stabilization of these fractures is controversial. Current initial management includes skeletal traction, skin traction, trac-tion splinting, and posterior splinting, all of which have advantages and disadvantages.

Literature on the initial tempo-rizing management is limited.

Skeletal traction in chil-dren is effective in the initial management of pediatric fe-mur fractures, yet the potential morbidity of placing a skel-etal traction pin is substantial. Physeal growth arrest follow-ing proximal tibial or distal femoral traction in children is a potential serious complica-tion. The psychological trauma of skeletal traction is also po-tentially detrimental. Skeletal traction has been shown to in-crease the pain medication and anxiolytic dose requirements and carries the morbidity of pin-site infections, as well as the risks associated with con-scious sedation.3 Imprecise traction pin placement has been shown to increase the incidence of varus or valgus alignment of the fracture.4

Skin traction has less mor-bidity compared with skeletal traction. However, the limited ability to pull a maximum of 5 to 10 lb of traction across the fractured limb reduces its ef-fectiveness in restoring axial alignment. Skin traction also

carries the risk of skin blister-ing and sloughing, especially in patients with altered sensa-tion. In addition, skin traction makes patient transfers chal-lenging.

Traction splinting using modern, commercially avail-able variations of the Thomas splint is commonly used in the field for transportation of femur fractures. Risks of traction splinting include skin breakdown on the foot and nerve stretch with peroneal nerve palsies.5 These splints can also limit neurovascular examination sensitivity due to their compressive nature. Traction splints should not be used for more than 6 hours.

Long posterior fiberglass or plaster splints are largely inef-fective for stabilizing femur fractures, especially if they are midshaft or more proximal (Figure 1). In the authors’ ex-perience, posterior splints do not provide the desired frac-ture stability or patient com-fort.

Numerous studies have discussed the definitive treat-ment of these fractures,3,4,6,7

Abstract: This article describes a novel splinting technique for the temporizing management of pediatric femur fractures. The J-splint is a reliable, simple, and rapidly applied splint that pre-vents many of the complications and pitfalls of other described temporizing measures, such as skeletal traction, skin traction, traction splinting, and posterior splinting. This technique of J-splinting femur fractures has low morbidity and provides many advantages in the temporizing management of pediatric femur fractures.

Drs Daniels, Kane, and Born are from the Division of Orthopaedic Trauma, and Dr Eberson is from the Division of Pediatric Orthopaedics, Department of Orthopaedics, The Warren Alpert Medical School of Brown University, Providence, Rhode Island.

Drs Daniels, Kane, Eberson, and Born have no relevant financial rela-tionships to disclose.

The authors acknowledge Michelle Daniels for her illustration assistance.Correspondence should be addressed to: Christopher T. Born, MD, Divi-

sion of Orthopaedic Trauma, Department of Orthopaedics, The Warren Alp-ert Medical School of Brown University, 2 Dudley St, MOC 200, Providence, RI 02905 (christopher_born@brown.edu).

doi: 10.3928/01477447-20120822-05

Temporizing Management of Pediatric Femur Fractures Using J-splints Alan H. Daniels, MD; Patrick M. Kane, MD; Craig P. Eberson, MD; Christopher T. Born, MD

774 ORTHOPEDICS | Healio.com/Orthopedics

n tips & techniques

yet few studies focus on the acute management and tem-porization of pediatric femur fractures. An optimal method for temporization in the acute setting would provide patient comfort, fracture stabilization, and minimal patient morbid-ity while allowing comfort-able and relatively easy patient transfers.

The authors’ technique of J-splinting femur fractures has low morbidity and provides excellent temporizing manage-ment for many pediatric femur fractures. This technique is in-dicated for any femur fracture in children too large for treat-ment in a Pavlik harness up to approximately 100 lb. This technique is more challenging to perform on larger children and adolescents, and skeletal traction may be recommended for adolescents if preferred by the treating surgeon.

TechniquePlacement of the J-splint

can be performed along with oral, intravenous, or intrana-sal analgesics and anxiolytics, with or without conscious se-dation. The procedure can be performed by the emergency medical technicians in the field or by the orthopedist or emergency physician with 1 or 2 assistants, depending on resources available.

The patient should be pro-vided with adequate analgesic and anxiolytic medication, as determined by the orthope-dist and emergency physician. Plaster splint material works well for this technique due to its ability to retain molding in the J configuration, although

fiberglass material can also be used. The authors use 4-inch- wide plaster rolls for children weighing less than 50 lb and 6-inch wide plaster for chil-dren weighing more than 50 lbs using a slab 8 to 10 layers thick (Figure 2).

The length is measured us-ing the contralateral leg as a template, from the axilla down the lateral torso and leg, around the foot, and up the medial con-tralateral leg into the groin. The plaster should be measured ac-curately and not overestimated, and folding over the ends of the plaster material should be avoided to avoid burns in the axilla or groin.

Once the plaster slab has been created, at least 5 lay-ers of Webril (Covidien, Mansfield, Massachusetts) or other cast padding should be laid over the top of the plaster longitudinally, with 6 inches of excess padding on each end. Adequate padding is nec-essary to avoid compression on bony prominences and to prevent skin burns. Additional padding with abdominal dressing pads may be placed at the ends of the splint to pad the axilla and groin more.

An assistant holds the fractured limb in anatomic rotational and varus/valgus alignment, pulling enough axial traction to make the limb appear well aligned. The or-thopedist wets the splint with cold or tepid water (less than 24°C8) to avoid burns and to allow adequate time for frac-ture reduction and splint mold-ing. The splint should then be applied with the padding fac-ing the patient (Figure 3).

Figure 3: Photograph of an assistant holding axial traction on the injured limb while the orthopedist places the J-splint. A second assistant is holding the splint in place.

3

Figure 2: Supplies for J-splint application.

2

Figure 1: Anteroposterior (A) and lateral (B) radiographs showing a femur fracture stabilized with a posterior splint applied by the emergency physician. Note the proximal extension of the splint ending at the fracture site level (red arrows).

1A 1B

SEPTEMBER 2012 | Volume 35 • Number 9 775

n tips & techniques

Elastic wrap is applied, with the appropriate size cho-sen based on the child’s size. Wrapping begins at the foot and should be tight enough to hold the splint in place but loose enough to avoid com-pression of the soft tissue and cause limitation in peripheral blood flow. The elastic wrap should continue up the injured extremity and include the torso to the ipsilateral axilla (Figure 4). The assistant should hold the limb in a straight position until the plaster is dry. The elastic wrap can be mobi-lized for physical examination needs based on the child’s as-sociated injuries and necessary distal neurovascular examina-tion.

case RepoRTAn 8-year-old boy

(weight, 28 kg) presented to the emergency department at reporting right leg pain following a collision during football practice. On physi-cal examination, his skin was intact, varus angulation of the leg at the area of the mid-femur was observed, his compartments were soft and compressible, and no neuro-logic or vascular deficits were found. Radiographic imaging revealed a transverse, right disphyseal femur fracture (Figure 3). Operative fixa-tion with flexible intramedul-lary nails was planned for the morning. While the patient was under light sedation in the emergency department, a J-splint was placed to assist with patient comfort and frac-ture alignment and to simpli-fy patient transfers (Figure

5). The patient was comfort-able overnight, receiving 1 dose of 2.5 mg of intravenous morphine for pain control.

DiscussionThe J-splint for the tem-

porizing management of pe-diatric femur fractures is a reliable, simple, and rapidly applied splint that can effec-tively stabilize most pediatric femur fractures until defini-tive care can be delivered. It supplants the use of skeletal or skin traction and traction splints and has numerous ad-vantages over other temporiz-ing stabilization techniques. In the authors’ experience, this technique is effective for children with femur fractures who are too large for treat-ment in a Pavlik harness but weigh 100 lb or less.

Advantages of J-splints in-clude the decreased time and complexity of application as compared with traction, and they are also a low-cost alter-native that does not require a traction setup. Furthermore, J-splints can be used in the field and in hospitals and clin-ics without the resources to place skeletal or skin traction. They can also be used in di-saster and mass-casualty sce-narios. This technique avoids the nerve stretch and compres-sion seen with traction splint-ing and can be used for longer than 6 hours.

This technique allows for ongoing physical exami-nation of skin, soft tissues, and neurovascular struc-tures without removal of the splint, especially in the case of high-energy injuries evalu-

ating for compartment syn-drome. Femur fractures can be associated with ipsilateral knee ligamentous injury, and J-splints work well to stabi-lize the knee in contrast with traction, which may cause additional injury to the neu-rovascular structures by pull-ing axial traction through a ligamentously injured knee.

J-splints also stabilize the an-kle and foot if ipsilateral limb trauma is present.

An additional benefit of the J-splint is in the treat-ment of children with mul-tiple injuries. Femur fractures in children often occur from high-energy trauma, and these patients often require multiple imaging studies; the J-splint

Figure 4: Photograph (A) and illustration (B) showing J-splint in place.

4A 4B

Figure 5: Presplinting anteroposterior radiograph showing a diaphyseal femur fracture in varus alignment in an 8-year-old boy (A). Postsplinting radiograph showing improved alignment of the femur fracture (B).

5A 5B

776 ORTHOPEDICS | Healio.com/Orthopedics

n tips & techniques

allows easy transfer into and out of the computed tomog-raphy or magnetic resonance imaging scanner. The splint or the elastic bandage can be easily removed to allow a chest and abdominal exami-nation.

LimiTaTions, peaRLs, anD piTfaLLs

Compared with skeletal traction, this technique is rel-atively ineffective in preserv-ing femur length. The J-splint performs well in terms of coronal alignment but is less effective in preserving axial length if significant shorten-ing is present, although the axilla and groin pad allow some axial traction. Although preserving axial length may assist with intraoperative fracture reduction, improved axial alignment from skeletal traction may not decrease nar-cotic requirement, and its ben-efits are controversial.9 The J-splint’s ability to preserve sagittal alignment varies with fracture pattern and the qual-ity of the splint. An additional pitfall of the technique is the

possibility of skin burns if the splint material is folded back on itself, if the water used for splint curing is too warm, or if inadequate padding used.

In patients with multiple injuries and severe injuries that will preclude them from definitive fracture treatment within 24 to 36 hours, skel-etal traction or skin traction may be beneficial in preserv-ing length, and the J-splint should not be used. An alter-native method of temporiz-ing stabilization of pediatric femur fractures is long poste-rior splinting, which extends proximal to the buttocks and can be effective in some situ-ations. J-splints are only to be used as temporizing stabiliza-tion and not definitive treat-ment. Furthermore, they are more difficult to apply and potentially less effective in children weighing more than 100 lb.

In patients who are unco-operative, require multiple invasive procedures, or re-quest sedation, a conscious sedation may be beneficial during splint application. For

splint application, various splinting materials may be used, including plaster, fiber-glass, or prefabricated pad-ded fiberglass splint material. Appropriate padding must be used with any splint material to avoid pressure sores and burns.

concLusionThe J-splinting technique

has low morbidity and pro-vides optimal temporizing management of some pediatric femur fractures. Further study is needed to examine the abili-ty of J-splints to improve frac-ture alignment and decrease narcotic requirements in pedi-atric patients with femur frac-tures.

RefeRences 1. Loder RT, O’Donnell PW,

Feinberg JR. Epidemiology and mechanisms of femur fractures in children. J Pediatr Orthop. 2006; 26(5):561-566.

2. Galano GJ, Vitale MA, Kessler MW, Hyman JE, Vitale MG. The most frequent traumatic orthopaedic injuries from a na-tional pediatric inpatient popu-lation. J Pediatr Orthop. 2005; 25(1):39-44.

3. Casas J, Gonzalez-Moran G, Albiñana J. Femoral fractures in children from 4 years to 10 years: conservative treatment. J Pediatr Orthop B. 2001; 10(1):56-62.

4. Aronson DD, Singer RM, Hig-gins RF. Skeletal traction for fractures of the femoral shaft in children. A long-term study. J Bone Joint Surg Am. 1987; 69(9):1435-1439.

5. Mihalko WM, Rohrbacher B, McGrath B. Transient pero-neal nerve palsies from injuries placed in traction splints. Am J Emerg Med. 1999; 17(2):160-162.

6. Hosalkar HS, Pandya NK, Cho RH, Glaser DA, Moor MA, Her-man MJ. Intramedullary nailing of pediatric femoral shaft frac-ture. J Am Acad Orthop Surg. 2011; 19(8):472-481.

7. Hedequist D, Bishop J, Hresko T. Locking plate fixation for pe-diatric femur fractures. J Pedi-atr Orthop. 2008; 28(1):6-9.

8. Halanski MA, Halanski AD, Oza A, Vanderby R, Munoz A, Noonan KJ. Thermal injury with contemporary cast-appli-cation techniques and meth-ods to circumvent morbidity. J Bone Joint Surg Am. 2007; 89(11):2369-2377.

9. Vanlaningham CJ, Schaller TM, Wise C. Skeletal versus skin traction before definitive management of pediatric fe-mur fractures: a comparison of patient narcotic require-ments. J Pediatr Orthop. 2009; 29(6):609-611.