**3. Neonatal femoral fractures**

A neonatal femoral fracture is a rare but severe complication of the birth. The reported incidence is about 0.1/10000 births [17]. Although was believed that elective cesarean delivery would eliminate the incidence of birth trauma, this is not confirmed, and several reported neonatal femoral fractures are associated with CS. Femoral fracture in CS is an extremely rare complication. Urgent CS, increased birth weight, breech position, fibromatosis of the uterus, inadequate uterine relaxation, inadequate incision in the uterine segment are reported as predisposing factors for femoral fractures in CS [1–5, 17–21].

The obstetrician may feel the cracking sound and observe the pathological mobility of the femur, but this is uncommon. The examining pediatrician and the nurse will notice the swelling of the fractured femur and the abnormal shape and movements of the leg. The neonate is crying and dressing is extremely painful. Suspicion for the fractured femur may not be noticed until the 2nd and 3rd day of the life. Mother will report the permanent irritation of the neonate, the difficulties for breast feeding, since every movement causes crying. A case of a spiral femur fracture diagnosed 9 days postpartum, after an elective CS for the breech presentation has been reported [22].

Diagnosis is confirmed with appropriate X-ray examination. Fractures commonly affect the proximal third and the diaphysis of the femur. The proximal part is shifted in flexion and abduction, due to the imbalance of the muscle action (**Figures 5** and **6**).

Treatment is provided with appropriate skin traction, either with Bryant's traction (both limbs suspended in the air vertically at 90°) or with simple skin traction. We use bilateral traction, with hips flexed in 90° and the buttock in a distance from the bed. We use simple skin traction in fractures in the middle third of the femur. Breast feeding becomes difficult, as the mother must lie in an uncomfortable position and the neonate is trying to feed by flexing the head, while it is in the traction. With patience and assistance from the nurse, this can be achieved. In premature children that must remain incubated or in the box, this traction is applied in their box [23, 24].

Fractures are united with excessive callus formation (**Figure 7**).

Usually a period of 2–3 weeks in traction is adequate to remove the traction. Use of Pavlik harness has also been recommended, with appropriate balance of the fractured

#### **Figure 6***.*

*Initial X-ray of the fractured femur with severe displacement in flexion and abduction of the proximal part. Treatment provided was skin traction with Bryant's method, for both legs.*

**Figure 7.** *Massive callus formation of the fractured right femur, in 2 months.*

parts of the femur but is not a stable position mainly during the first week. Use of the harness requires frequent adjustments and the nursing stuff is unfamiliar with these corrections. We recommend the use of the harness after at least 10 days of traction,

with caution, since the oversight of a pediatric orthopedic surgeon is of great importance in order to retain the appropriate reduction. Alternative methods of immobilization have been reported. Strapping the thigh to abdomen or the use of a hip spica are also described methods of immobilization [18]. We recommend for the neonate with a fractured femur the use of skin traction with Bryant's method as the safest and comfortable treatment. We have treated 5 neonates with femoral fractures, using skin traction over the past 20 years and we report very good results. We have not observed any rotational deviations and no leg length discrepancy in the first years of life.

The natural history is the early remodeling of the fracture. The child is observed up the age of 2–3 years old, to ensure the final leg length discrepancy and the appropriate shape of the femur. During the treatment period with skin traction it is of paramount importance to correct possible severe external rotation of the femur, since rotational deformities are not corrected with the remodeling process (**Figures 8** and **9**).

Surgical treatment is not recommended for the neonatal fracture. A case from Italy was reported using an external fixator for a neonate with lumbar myelomeningocele and fractured femur [25]. In case that fractured parts show severe angulations that must be corrected with appropriate change of the traction. We have treated an extremely rare case of a neonate that the fractured segment was caught under the skin. Despite the use of Bryant's traction and appropriate manipulation this was not corrected. We performed a minimal skin incision to reduce the fracture by splinting the muscles and stabilized temporally the segments with a K-wire and hip spica.

**Figure 8.** *Excessive callus formation at 3 weeks of the fractured neonate femur.*

**Figure 9.** *At 1 year there is complete remodeling of the fractured left femur.*

**Figure 10.** *Severe displacement and entrapment of the proximal part under the skin, despite use of Gallow's traction*.

The neonate was closely observed with appropriate support from neonatologists. He had an uneventful recovery (**Figures 10** and **11**).
