Lower limb injuries in children

by Stewart Dix-Peek & Benjamin Blankson

Learning objectives

  1. Identify and diagnose lower limb paediatric fractures.
  2. Institute emergency management protocols for the fracture in an acute setting.
  3. Understand the definitive management protocols for various lower limb fractures.


Fractures make up about 10–25% of all injuries in the paediatric population1. Of these, lower limb fractures make up approximately 15.9%2 and the prevalence increases with age1,2. These are mostly due to high-energy trauma from motor vehicle accidents (MVAs), sports injuries, falls from heights and non-accidental injuries (NAI) among others2. A study conducted in the Red Cross War Memorial Hospital revealed falls from height (39%) as the major cause of femur fractures in the toddler group (peaking at 2 to 3 years). Next was MVA peaking at 4 to 5 years (33.7%); struck by foreign objects (11%); NAI, pathological fractures and sporting injuries followed in descending order3. This chapter will focus on highlighting lower limb fractures in a child and various protocols for management. Generally, patients need to be assessed initially and stabilised according to ATLS principles.

Specific injuries

Hip fracture


Hip fractures are rare in children. They usually occur from high-energy trauma, particularly MVA and a high index of suspicion is needed to diagnose them. X-ray (AP and lateral views) are essential to make the diagnosis, and a CT scan may be indicated for occult fractures. Below is a table summarising how hip fractures are classified.

Type I Transepiphyseal fracture, with or without dislocation of the femoral head.
Type II Transcervical. Usually displaced.
Type III Cervicotrochanteric
Type IV Intertrochanteric


Hip dislocation


Posterior dislocations account for 80% of hip traumas. Low energy injuries cause traumatic hip dislocations in the younger child (2–5 years) due to associated ligamentous laxity. In older children (11–15years), dislocated hips are caused by higher energy injuries and have a higher association with acetabular fractures, although this is rare. Dislocations are more common than fractures in the paediatric population.

Right hip dislocation
Right hip dislocation


Conduct a careful neurovascular evaluation with particular attention to the sciatic nerve. Ipsilateral femoral shaft fracture should be excluded before manipulation.


If an acetabular fracture is identified on the pre- or post-reduction X-rays, Judet (45° obturator and iliac oblique) views should be obtained. If an intra-articular fragment or incongruent reduction is present, a CT scan is indicated.


Exclude an ipsilateral femur fracture before reduction. Assess neurovascular status (especially sciatic nerve function) both before and after reduction. Acutely, attempt closed reduction under procedural sedation, as this is usually successful. In delayed or neglected cases, traction for 3–6 days should be attempted before open reduction if an initial attempt of closed reduction was unsuccessful. Once the hip is reduced, immobilise in traction for 4–6 weeks.

Open reduction is rarely necessary; surgical intervention is indicated in:


Femoral shaft fractures


Femoral shaft fractures present with a bimodal distribution peaking at 2–4 years and mid-adolescence, predominantly in males. In the neonate, fractures are mainly due to birth trauma and non-accidental injury. In children under one year, 50% are due to non-accidental injury and, in adolescents, most are due to MVA.


Descriptive Anatomical
  • Open/compound
  • Pattern: spiral, transverse, short oblique, long oblique, butterfly fragment, comminuted
  • Displacement
  • Angulation
  • Subtrochanteric
  • Shaft
  • Proximal 1/3
  • Midshaft
  • Distal 1/3
  • Supracondylar (metaphyseal)


The table below summarises the accepted angulation in a femur fracture.

Age Varus/valgus Anterior/posterior
0–2 years 30° 30°
2–5 years 15° 20°
6–10 years 10° 15°
>11 years 10°

Below are guidelines to management of femur shaft fractures; however, these may vary between facilities, depending on the preference and expertise of the surgeons.

Age Treatment Duration Comments
Neonates Pavlik harness 3 weeks
<2yr / <12kg Gallows traction 3–6 weeks Compartment syndrome risk
2–8 years Early spica cast 4-8 weeks
8–12 years Traction 6–8 weeks
Retrograde IM nails Partially weight bearing to full as pain permits Removal at 6 months
>12 years Prograde IM nails Trochanteric entry point. Locked nail
Special circumstances
Compound fractures External fixator/plate with preliminary debridement, antibiotics
Severe head injury ORIF (done once patient’s condition stabilised)
IM nails = intramedullary nails
X-rays of (A) Retrograde IM nail and (B) Prograde IM nail
X-rays of (A) Retrograde IM nail and (B) Prograde IM nail
Gallows traction
Gallows traction


Knee injuries


In the immature skeleton, physes fail before ligaments under tensile load. Ligamentous injuries are therefore uncommon before skeletal maturity. Two-thirds of the longitudinal growth of the lower limb occurs in the distal femur (10 mm/year), followed by the proximal tibia (6 mm/year). Injuries to the physes may lead to premature growth arrest or angular deformity.

Distal femur fracture

Ligamentous and tendinous structures insert on the epiphysis, leaving the physis unprotected. Injury is usually due to indirect forces: varus/valgus hyperextension/hyperflexion, usually resulting in a Salter-Harris II type injury.

Radiological evaluation

AP and lateral films should be ordered. Oblique views are needed when in doubt or to visualise the fracture better. Stress views may be necessary to identify undisplaced fractures. In infants, separation of the distal femoral physis may be missed. The ossified centre of the epiphysis should always be in the line of the femoral anatomic axis on AP and lateral.


Salter-Harris Displacement
Type I:Easily missed. Stress views may be necessary. Hyperextension injury – anterior
Type II:Most common type. Usually varus or valgus injury. Hyperflexion injury – posterior
Type III:Intra-articular. Often best seen on AP X-rays as the physeal component is in the sagittal plane. Varus injury – medial
Valgus injury – lateral
Type IV:Rare injury but a high incidence of linear physeal bar formation.
Type V:Diagnosis usually made retrospectively.
Salter Harris type I fracture of distal femur Stress view with valgus force Stress view with varus force
Distal femur fracture: (A) Salter Harris type I fracture of distal femur; (B) Stress view with valgus force; (C) Stress view with varus force


In the older child with a large metaphyseal spike (Thurston-Holland fragment), the fragment may be used to maintain reduction with cannulated lag screws.




Physeal closure: 50% of physeal injuries in the distal femur will result in arrest. This is due to the interdigitating nature of the distal femoral physis. The physeal injury will present with a bar manifesting as angular deformity or limb length discrepancy.


Modified images:
Dislocated hip. Available from: