managment femoral fractures

8/9/2019 Managment Femoral Fractures

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Update on Management of

Femoral Fractures

in Children

James G Jarvis

25th Ste Justine Pediatric Orthopaedic Review Course


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Objectives

Unique properties of pediatric patients

Femoral shaft fracturesAge based treatment options

Distal femur fractures

Metaphyseal

Physeal


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Pediatric Fractures

Unique properties of theimmature skeleton:Increased resil iency to stress

Presence of a physis

Thicker periosteum

Increased potential to remodel Age, location of fx, plane of deformity

Shorter healing times


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Femur Fractures General

Child < 2 y think abuse

If high energy mechanism get TraumaSurgery eval.

Always check AP pelvis femoral necks andSI joints

Timing of f ixation not as critical as in adults

Pre-op Bucks traction vs. extra long legsplint


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ER Management

Principles:

Stabilize patient (ATLS)

Stabilize leg for comfort,

avoiding further injury

Prepare for definitivetreatment in t imely

fashion


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Traction Options

Skin: Good for smaller weights (5lbs or less)

Easy to apply and use with Thomas or other

set-up

Skeletal: Generally for older chi ldren

(greater weight needed)

For long term traction

Better control of distal

fragment90-90 skeletal traction


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Traction - Set-ups

Very surgeon specific

Common:Attempt to control

rotation, length, andangulation

Comfort andpracticality important

Bryant's, Bradford etc.


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Treatment Goals

Union of the fracture

Minimize shortening,angulation, rotation

Minimize soft tissuecomplications

Minimize Social &

Financial costs


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Femoral Fractures in Children

70% Mid-shaft

18% Proximal

12% Distal


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Femoral Shaft Fractures

Davis Podeszwa MD

TSRH Dallas


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Treatment Options:

Depend on Age & Injury 1. Traction (Mostly Historical in North America)

2. Pavlik Harness 3. Spica Cast (with or without traction)

4. Flexible Intramedullary Nail

5. Rigid Intramedullary Nail 6. Internal Fixation

7. External Fixation


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Historical Treatment

Bryants traction

For temporary treatment

High rate of complications


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Femoral Shaft

Fractures: 0-1 year

Immediate spica vs. Pavlikharness

4 to 6 weeks of immobilizationdepending on age (age + 3)


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Femoral Shaft

Fractures: 0-1 yearPavlik Harness

Easily applied/well tolerated

Flex hips to ~ 80-90 ( looseabduction )Avoid femoral nerve palsy

< 4 - 6 mos of age

Podeszwa et al. JPO2004


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Femoral Shaft

Fractures: < 4 years oldImmediate Spica

Cast Adequate sedation and help

90/90 posit ion Depends on level of fx

May increase risk ofcompartment syndrome

Valgus mold on injured side

Mubarak et al. JPO2006


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Early vs. Delayed Spica

Init ial X-ray shortening

< 2 cm early spica> 2 cm consider delayed spica

Telescope test


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Deforming Forces


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Extremity Length

Overgrowth

Most common in 3 9 year

old age group

Most overgrowth occurs

within 12 to 18 months

Averages ~ 1 cm


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Angular Malunion

Excellent remodelling


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Rotational Malunion

Siebert(Unfallchirurgie 1994)

15/25 (60%) corrected by 4 year f/u Brouwer (Acta Orthop Scand 1981)

49/50 corrected at 27-32 year f/u Oberhammer(Arch Orthop Trauma Surg 1980)

124/124 infants corrected by 4-6 yearfollow-up

Hagglund(Acta Orthop Scand 1983)

Anteversion difference 9.60 5.60at10 year follow-up

F l Sh ft


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Femoral Shaft

Fractures: 4-12 years

Flexible IM Nail Current method of choice

Titanium vs Stainless (Enders) Retrograde or antegrade

Medial and lateral vs. lateral only

80% canal f it

Ideal patient 20-50 kg

Stable fx pattern transverse or short oblique

middle 60% of shaft


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Femoral Shaft

Fractures: 4-12 yearsFlexible IM Nail Unstable fx patterns

(long oblique, comminuted, or proximal)

Sink et al. (JPO2005) 60% complications

Jarvis et al (J Trauma 2006)- subtroch #s

Rathjen et al. (JPO2007) no increased

complication rate if cortical abutment

Ellis et al. (JPO2011) - lock rods distally

prevents shortening, ? Rotation


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Case #2--9 y/ogirl, hit by car

Isolated injury


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F l Sh ft


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Femoral Shaft

Fractures: 4-12 years

Flexible IM Nail

Complications Pain at insertion site most

common

Pts > 50 kg increased riskof LLD, angulation,malunion

Moroz et al. JBJS-Br 2006

Sink et al. JPO 2005

Flynn et al. JPO 2001


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Ends of nails can cause

soft tissue irritation


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12 yo 200 lb female unstable fx

treated with flexible nails healed

with 30 degree procurvatum malunion


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ORIF Plate Fixation


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ORIF with Plates/Screws

AdvantagesRigid

Familiar technique

Allows early motionUseful in head-injured

Disadvantages

Large scar

Refracture after plate removal

Increased infection rate (earlier series)

F l Sh ft


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Femoral Shaft

Fractures: 412 years

Sub-muscular Plating

Comminuted, long spiral, very

proximal, distal 1/3

Internal Ex Fix concept

Remove at 1 year to avoid bony

overgrowth

Agus et al . JPO 2003

Sink et al. JPO 2006

Pate et al. JPO 2009


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Percutaneous

Bridge Plating

Courtesy of E.M. Kanlic, MD, PhD


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Rigid IM NailsPiriformis Entry

Technically possible, esp in

teenagers

Increasing reports of proximal

femoral AVN

Lateral ascending branches of MCFA

AVOID in pts with open physes

P i l F l Bl d


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Proximal Femoral Blood

Supply


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Piriformis Fossa Entry

Site

Raney E. JPO, 1993.

Thometz J, JBJS 1995.

Astion D, JBJS 1995


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Case #3--13 y/o

boy, skiing injury

Physes open


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17 months

post-op

23 months

post-op


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Rigid IM Nails

Trochanteric Entry

Common indications: open physes

> 50 kg

> 11 years old

comminuted or segmental fx

Nails now available as small as

7 mm diameter

Complications:

Trochanteric arrest w ith

valgus overgrowth

Trochanteric f racture

Varus deformity at fx

Gordon et al. JBJS-AM 2003

Gordon et al. JOT 2004

Keeler et al. JPO 2009


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External Fixation

Generally reserved for damage control

Severe comminution, soft tissue injury, head injury, vascular

injury, life threatening injuries

1-1.5 cm shortening, 10 angulation acceptable

Complications:

Delayed union, re-fracture, pin infection Most likely in transverse, short oblique fx

Barlaset al.Acta Orthop Belg 2006Blasier et al. JPO1997


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External Fixation

Frequent Re-fracture

Stress shielding poor callus

10-20% rate Fracture pattern dependentSpiral least l ikely

33% if callus on 1 or 2 cortices, 4% if

callus on 3 or 4 cort ices (Skaggs, J Ped Orthop 19(5):582-86)


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Day of Injury


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11 weeks 11 weeks + 1 day


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Prevention of Refracture

Dynamize at 4 6 weeks

Full weightbearing at 4 6 weeks

Protect in walking cast if transverse orshort oblique fracture pattern


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Distal Femoral Fractures


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Distal Femur Fractures

Classification

Metaphyseal

PhysealSalter-Harris I 7.7%

II 60%

III 10%IV 10%

V 6%


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Mechanism

Partly age dependent Newborn breech,

birth fx, S-H I 3-10 y severe trauma

Adolescents sportsinjuries

Overall Peds vs. MVA 45-50%

Sports 25%

Falls 20%


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Treatment Basic Principles

Anatomic reduction

PhysesArticular surfaces No step-off,


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Metaphyseal

Treatment

CR, percutaneous pinningPreferred method

Hyper-extension vs. hyper-flexion

Avoid physis if possible

Smooth pins if cross physis

ORIFOlder/bigger child

Proximal fracture


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Physeal

Treatment

General anesthesia/sedation

Traction with manipulation

No attempt after 10 days

Anatomic reduction S-H III/IV

Avoid physis if possible, non-threaded if

cross physis



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Distal Femur FracturesPhyseal

Treatment

Casting

Non-displaced S-H I/II

CR, percutaneous pinning

Displaced S-H I or S-H II with smallfragment

Pins out 4 wks, cast for 6 total


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Physeal

Treatment

CR, percutaneous screw fixationCannulated screws (4.5/6.5 mm)S-H II with large fragment

Cast x 6 wks

ORIFS-H III/IV


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Di t l F F t


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Complications AcuteArterial injury

Displaced, hyperextension

injuryPeroneal nerve injury

Incidence 5%

Direct trauma or severe

varus producing force

Ligamentous injury

Incidence 23-38%

ACL, LCL, MCL most

common

Delayed

Physeal arrest - LLD

Incidence ~ 1/3

Risk factors High energy, young age,

severe displacement,

comminuted fractures

Angular deformity

Incidence 29%

Loss of knee motion

Incidence 27%


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Summary

Unique properties of pediatric patients

Femoral shaft fractures

Age based treatment options

Distal femur fractures

Metaphyseal

Physeal


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Update on Management of

Femoral Fracturesin Children

James G Jarvis

25th Ste Justine Pediatric Orthopaedic Review Course

managment femoral fractures

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