Femur Fxby Tahir

Pediatric Femoral Shaft Fractures

Dr. Tahir Mahmood Lahore General Hospital Lahore

Pediatric Femur Fractures     

1.6 % of all children Fractures 28/100,000 child per year 3:1 Male / Female ratio Children >3 yrs- highest incidence Seasonal- highest summer

Anatomy and Growth 

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Proximal femoral physis- 30% of longitudinal growth Distal femoral physis70% of longitudinal growth Rapid increase in cortical thickness

Pediatric Femur FracturesMechanism of Injury     

Rule out child abuse Falls- young children/toddlers Struck by vehicle- juvenile Recreational sports/activities- adolescent Motor vehicle crashes- all age groups

Mechanism of Injury  

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Low Energy High Energy predicts behavior/treatment of the fracture

Pediatric Femur FracturesAssociated Injuries 

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Struck by car- triad of femur fracture, torso injuries, head injury Potential damage to physis of femur and proximal tibia Head Injury – spasticity can make traction and cast treatment difficult Abdominal injury – spica cast can constrict abdomen and limit ability to examine

Spasticity Leading to Extreme Angulation and Shortening

Physical Exam 

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Complete exam: head, chest, abdomen, and other skeletal segments Document distal neurological and vascular function Palpate all bones First Aid principles - Splint or traction, especially prior to transfer to another institution

Radiographic Evaluation   

AP Pelvis AP/Lat femur Visualize hip & knee joints

Classification 

Fracture pattern 

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transverse, spiral, oblique, comminuted, greenstick

Amount of shortening Angular deformity Open / closed

7 Principles Dameron & Thompson   

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1. Simplest treatment best 2. Initial treatment permanent when possible 3. Perfect anatomic reduction not essential for perfect function 4. More potential growth= more remodeling capability

7 Principles Dameron & Thompson JBJS 1959 

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5. Restoration of alignment more important than fragment position 6. Over treatment usually worse than under treatment 7. Immobilize/splint injured limb before definitive treatment

Treatment Goals - Restore   

Length Alignment Rotation

Treatment Goals - Avoid

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Osteonecrosis - disruption of blood supply to femoral head Physeal injury- preserve future growth potential (proximal and distal femoral physis, trochanteric apophysis)

Complication of fracture femur 

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Leg length discrepancy shortening over growth Angular deformity Rotational deformity Delayed union

Complication of fracture femur     

Non union Muscle weakness Infection Neurovascular injury Compartment syndrome

Decision Making   

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Age Mechanism of injury Fracture pattern & location Associated Injuries Surgeon preference Available resources

Treatment options Age Birth to 24 mo 

2 yrs to 5 yrs

Treatment. padding & soft splint Pavlik harness (newborn to 6 mo) Immediate spica cast Traction ~spica cast Immediate spica cast Traction ~ spica cast External fixation (rare) TEN (rare)

Treatment options 6 yrs to 11 yrs

Traction ~ spica cast Compression plate TEN External fixation

12 yrs to maturity

TEN Compression plate Locked IMN External fixation

Acceptable angulations Varus/ Anterior/ Shortening Valgus Posterior (mm) (degrees) (degrees) Birth to 2yrs 30 30 15 2-5 yrs 15 20 20 6-10 yrs 10 15 15 11yrs to maturity 5 10 10 

Age

Traction Techniques  

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Skin or skeletal Longitudinal in line traction for comfort prior to definitive treatment Longitudinal in line traction for comfort prior to definitive treatment

Traction Techniques 

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Vertical over head traction hip flexed 90 degree (Bryant 1973) Split Russells traction (90-90) if awaiting early healing prior to casting

Skeletal Traction Techniques 

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Avoid physis if place skeletal traction pins Place pin perpendicular to shaft to avoid varus/valgus angulation

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Subtrochanteric fracture treated with traction followed by one legged ambulatory spica cast

Immediate Spica Castideal patient    

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Less than 5 years old Less than 50 lbs Initial shortening not excessive Isolated injury Note -Spica casts used for decades and can work for almost any pediatric femur fracture

Spica Cast Technique  

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Appropriate padding Cast liners may decrease skin problems Traction to get 0-15 mm shortening Mold laterally to prevent varus Can wedge for unacceptable angulation at 1-2 week checkups

Spica Cast 

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Fiberglass lighter, easier to x-ray through Often strong enough to obviate need for connecting bar

Sitting spica – 3 part, 90-90

This technique, recommended in textbooks and articles, may increase risk of developing compartment syndrome

Current technique – Above knee cast first. Hip and knee- 40-45 flexion, foot out. Can include opposite thigh if desired.

Immediate Spica Cast 

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X-ray weekly for 3 weeks Time in spica = age in years + 3 weeks up to maximum 8 weeks Wedge cast for malalignment Rotational alignment important at initial cast application

Complications 

Closed treatment of children’s femur fractures resulted in the most frequent and expensive complications, including foot drop, skin loss, compartment syndrome, and malrotation / shortening.

Compartment syndrome complicating early spica cast treatment of isolated femoral shaft fractures in children - JBJS Nov 03

Mold into slight valgus desired on initial radiograph after casting

Femoral Remodeling after Fracture 

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Will not correct significant rotational malunion (Davids, Clin Orthop) Overgrowth 1-1.5 cm may occur, especially in younger children treated nonoperatively Angular deformity will remodel significantly in children <5 years old, less reliably in 5-10 year old, and is unlikely to be substantial in children >10 years old

Trend Toward More Invasive Treatment     

More high energy fractures Improved operative techniques Failed nonoperative treatment Simplifies patient care Psychological, social and financial reasons

Ambulatory Treatment Options     

Plate & screw fixation External fixation Flexible nailing Rigid nailing Bridge plating / MIPPO/ locked plates

Flexible Nailing 

Advantages 

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Allows early mobilization without cast Cosmetic scars Avoids physis and blood supply to femoral head

12 yo male in RTA accident Closed proximal third, oblique fracture Back at school 2 weeks Walking at 8 weeks

Flexible Nailing  

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Disadvantages Ends may irritate soft tissues May not be amenable to some fracture patterns (very proximal or distal, comminution)

Flexible Nails 

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Titanium elastic intramedullary nailing (TEIN) popular choice to stabilize pediatric femur fractures in children > 5 yrs little published on complications JBJS Br 2006 Healed 5 cm short

Most complications – minor

Nail Irritation (16%) don’t bend ends - all resolved post

Cut pins above physis with screw cutter

13yo male, 94 lbs -nails too short, back out, get infected, have to be removed, varus malunion with shortening

12 yr old female, 130 lbs Varus, procurvatum malunion

TEIN yielded excellent or satisfactory results in 90% of cases

Outcome was better in a higher percentage of central-third fractures

Be aware of prox 1/3- mid 1/3 junction fracture with medial butterfly

Recommendations : > 11 years, > 108 lbs – consider other treatment options

ORIF with Plates/Screws 

Advantages      

Anatomical reduction Rigid fixation Technique familiar to most surgeons Allows early motion Simplified nursing care Favorable results reported in children with associated head injuries

ORIF with Plates/Screws 

Disadvantages     

Large scar Implant failure Possible refracture after plate removed Second anaesthesia for implant removal Higher infection rate

ORIF Plate Fixation

Percutaneous Bridge Plating

Previous fracture with endosteal callus- plate good option

External Fixation 

Advantages  

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can be applied rapidly, allows soft tissue injury management , early mobilization, Good option in open fractures & poly trauma patients

External Fixation 

Disadvantages    

pin site sepsis, pin site scarring, refracture, malunion

11 yrs male RSA Pelvic fracture, ruptured bladder External fixation

Ex Fix Fracture at Prox Pin

Keep pin diameter <20% of bone diameter.

Ex Fix Refracture

6 months post injury

External Fixator Tips  

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Appropriate size half pin diameter Proper pin placement relative to fracture for biomechanical rigidity Do not remove ex fix until see bridging cortices

Medium Multi-Pin Clamp 2cm

2cm 2cm

2cm

Clamp is parallel to bone Schanz screw is perpendicular to bone

Open Femur Fracture Principles 

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IV antibiotics, tetanus prophylaxis emergent irrigation & debridement skeletal stabilization External fixation best option with severe soft tissue injury soft tissue coverage

Open Fractures

Can use temporary shunting to restore distal perfusion during debridement

Trochanteric Nail Technique   

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Stay out of piriformis fossa Some use large incision/open approach Over ream/small nail - starting hole and canal nonlinear Large diameter nail – ? benefit (no reported nail fractures, nonunion rare)

Piriformis Fossa Entry Site

Thometz J, JBJS 1995.

Astion D, JBJS 1995 Raney E. JPO, 1993.

Anatomy- Blood Supply Proximal Femoral Epiphysis Predominantly ascending cervical branch (B) of medial circumflex femoral artery Physis (D) - a barrier to intraosseous blood supply from femoral neck

Ganz, et al

12 year old male, 6 mos

Small diameter solid nail, unreamed

Trochanteric entry Proximal and distal interlocking

Leave some bone medial to nail

Nail removal  

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Some controversy Commonly recommended Survey studies – remove IM devices in children Outpatient procedure Grasping pliers No sports for 4 weeks Return for x-ray 4 weeks post removal

Summary   

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< 5 years – early spica cast, changed technique 5-11 years, < 100 lbs – TEN > 11, > 100 lbs – trochanteric entry nail or bridge plating Very distal or very proximal fracture, closed IM canal, or severe axial instability – bridge plating Severe soft tissue injury- external fixation