OTA RCFC 2.0, 2014OTA RCFC 2.0, 2014Presented by members of POSNAPresented by members of POSNA

Pediatric Femoral Pediatric Femoral Shaft FracturesShaft Fractures

Treatment Varies with Treatment Varies with Age…Age…

…but age isn’t the only factor to consider

IM Fixation is Far From the IM Fixation is Far From the Only Fixation Option Only Fixation Option

Open Plating External Fixation Submuscular Plating

How Much Do We Really How Much Do We Really Know?Know?

Clinical Practice Guidelines

AAOS Clinical Practice AAOS Clinical Practice GuidelinesGuidelines

Questions:Questions: What are the advantages of surgical stabilization over What are the advantages of surgical stabilization over

casting?casting? Is one form of surgical stabilization superior to another?Is one form of surgical stabilization superior to another? Which treatments have the best evidence to support Which treatments have the best evidence to support

their use?their use?

Evidence BasedNo Industry Funding

Complete Literature Review

14 Recommendations 2: Good Evidence 6: Poor Evidence 6: Insufficient Evidence

AAOS Clinical Practice AAOS Clinical Practice GuidelinesGuidelines

Age Recommendation Evidence

< 36 Mos Evaluate for Abuse Good

≤ 6 Mos Spica Cast and Pavlik are Treatment Options Poor

6 Mos–5 Yrs

Immediate or Delayed Spica Casting if < 2cm Shortening

Good

5–11 Yrs Flexible Nails are a Treatment Option Poor

> 11 YrsTrochanteric Nails, Submuscular Plates and Flexible Nails are Treatment Options

Poor

AAOS. “Treatment of pediatric diaphyseal fractures: guideline and evidence report.” 2009

Unable to Recommend For Or Against…Unable to Recommend For Or Against…

Removal of HardwareRemoval of Hardware

Physical TherapyPhysical Therapy

Using Weight as a Using Weight as a Treatment CriterionTreatment Criterion

Using Any Amount of Using Any Amount of Rotation or Angulation as a Rotation or Angulation as a Criterion for Altering Criterion for Altering TreatmentTreatment

Does This Help?Does This Help?

AAOS. “Treatment of pediatric diaphyseal fractures: guideline and evidence report.” 2009

19 month old: Fall From 19 month old: Fall From BedBed

History of Femur Fracture During Delivery Treated in Pavlik Harness

I want to…I want to…A.A. PPut the kid back in a Pavlik ut the kid back in a Pavlik

Harness. It worked the first time. Harness. It worked the first time.

A.A. Reduce the fracture to it pre-Reduce the fracture to it pre-fracture alignment and apply a fracture alignment and apply a spica cast. She’ll remodel that spica cast. She’ll remodel that femoral bow with time. femoral bow with time.

A.A. Reduce the fracture to anatomic Reduce the fracture to anatomic alignment and apply a spica cast.alignment and apply a spica cast.

A.A. Do a femoral osteotomy to correct Do a femoral osteotomy to correct the deformity and fix it with the deformity and fix it with flexible nails.flexible nails.

B.B. Do a femoral osteotomy and plate Do a femoral osteotomy and plate it. It’ll be tricky passing nails as it. It’ll be tricky passing nails as the intramedullary canal may be the intramedullary canal may be occluded due to the prior fracture occluded due to the prior fracture

Spica AppliedSpica Applied

FRACTURE REDUCED TO PRE-FRACTURE ALIGNMENT

6 Weeks Later….6 Weeks Later….

What’s Your Plan?

6 Weeks Later….6 Weeks Later….

SPICA REMOVED

3 Months Later: Fall from a 3 Months Later: Fall from a Standing Height Standing Height

SPICA REMOVED

I want to…I want to…A.A. Accept the deformity and pAccept the deformity and put the ut the

kid back in Spica…but keep it on kid back in Spica…but keep it on longer this time.longer this time.

A.A. Reduce the fracture to anatomic Reduce the fracture to anatomic alignment and apply a new spica alignment and apply a new spica cast.cast.

A.A. Accept the deformity and place Accept the deformity and place flexible IM nails . The nails will flexible IM nails . The nails will prevent re-fracture while she prevent re-fracture while she remodels the deformity. remodels the deformity.

A.A. Do a femoral osteotomy to correct Do a femoral osteotomy to correct the deformity and fix it with flexible the deformity and fix it with flexible nails.nails.

B.B. Do a femoral osteotomy and plate it. Do a femoral osteotomy and plate it. It’ll be tricky passing nails as the It’ll be tricky passing nails as the intramedullary canal may be intramedullary canal may be occluded due to the prior fracture occluded due to the prior fracture

Spica Applied with Femur in Anatomic Spica Applied with Femur in Anatomic AlignmentAlignment

6 Weeks Later….6 Weeks Later….

Spica CastingSpica Casting

Immediate Casting Immediate Casting Traction + Delayed CastingTraction + Delayed Casting Supplement to Internal Fixation Supplement to Internal Fixation

Contraindications:Contraindications: PolytraumaPolytrauma Skin Issues Skin Issues Shortening > 2.5 cm (relative)Shortening > 2.5 cm (relative) Altered sensation (relative)Altered sensation (relative)

Alternative Treatments:Alternative Treatments: Flexible IM NailsFlexible IM Nails External Fixation External Fixation Plate and ScrewsPlate and Screws

6 Year Old: Fell from 6 Year Old: Fell from ScooterScooter

I would treat this with…I would treat this with…

A.A. A Spica Cast: The parents will hate it but A Spica Cast: The parents will hate it but it’ll spare the kid a surgery. it’ll spare the kid a surgery.

A.A. A Submuscular Plate: It’ll have to be long but I A Submuscular Plate: It’ll have to be long but I don’t think flexible nails will maintain proper don’t think flexible nails will maintain proper length with this long spiral fracture pattern. length with this long spiral fracture pattern.

A.A. Flexible Nails: That’s the book answer for a 6 Flexible Nails: That’s the book answer for a 6 year old right?year old right?

A.A. A Rigid Trochanteric Entry Nail: It has all the A Rigid Trochanteric Entry Nail: It has all the benefits of flexible nails but I can lock it benefits of flexible nails but I can lock it distally to maintain length!distally to maintain length!

B.B. An External Fixator: It hasn’t been mentioned An External Fixator: It hasn’t been mentioned as an option for any questions so far. Since it’s as an option for any questions so far. Since it’s an option here its probably the right answer. an option here its probably the right answer.

Flexible IM NailsFlexible IM Nails

1 Week Post-Op 12 Weeks Post-Op

Flexible Intramedullary Flexible Intramedullary NailsNails

Ideal Patient:Ideal Patient: Age: 5 - 11 YearsAge: 5 - 11 Years Weight: < 50 kg Weight: < 50 kg Mid-Shaft FractureMid-Shaft Fracture

Actual Practice:Actual Practice: Ages 2 – 14 yearsAges 2 – 14 years Any Fracture LocationAny Fracture Location All Fracture Patterns All Fracture Patterns

Length Unstable FXS: Consider Length Unstable FXS: Consider LockingLocking

Various Nail Materials and Various Nail Materials and ConstructsConstructs

External Fixation External Fixation Used Less FrequentlyUsed Less Frequently

Indications:Indications: Open FracturesOpen Fractures Multiply Injured Patient?Multiply Injured Patient? Floating Knee?Floating Knee? Severe Comminution?Severe Comminution?

Downsides:Downsides: High Re-Fracture RateHigh Re-Fracture Rate Pin Site InfectionPin Site Infection Delayed Union Delayed Union

11 year old (40 kg): Kicked 11 year old (40 kg): Kicked By A HorseBy A Horse

I’d Fix This With…I’d Fix This With…

A.A. Retrograde Flexible Retrograde Flexible NailsNails

A.A. Anterograde Flexible NailsAnterograde Flexible Nails

B.B. Submuscular PlatingSubmuscular Plating

A.A. Open PlatingOpen Plating

B.B. External Fixation External Fixation

Open PlatingOpen Plating

Other Options…Other Options…

Anterograde Flexible Nails Submuscular Plating

Open PlatingOpen Plating AO Principles AO Principles

Good Option For:Good Option For: Proximal FracturesProximal Fractures Some Open Fractures Some Open Fractures

Downsides:Downsides: Extensive DissectionExtensive Dissection Blood LossBlood Loss Plate Removal Plate Removal Stress RisersStress Risers

3 year old: Motor Vehicle 3 year old: Motor Vehicle Collision Collision

What Else Do We need to Know About?

Associated Injuries….Associated Injuries….

Right Femur Left Hip Right Ankle Left Wrist C-Spine

How Should We Treat the Right Femur?

A.Spica CastB.Skeletal Traction

C.Flexible NailsD.External Fixation

E.Open or Submuscular Plating

Traction Film:Traction Film:

Does this change your plan?

ORIF Femur:ORIF Femur:

3.5 LCDC Plate

……and treat everything and treat everything else.else.

Sub-Muscular PlatingSub-Muscular Plating Increasingly PopularIncreasingly Popular

Good Option For:Good Option For: Comminuted FracturesComminuted Fractures Distal Fractures Distal Fractures

Downsides:Downsides: Learning CurveLearning Curve Stress RisersStress Risers Plate Removal Plate Removal Valgus Deformity? Valgus Deformity?

Rigid IM NailingRigid IM Nailing

Typical Indications:Typical Indications: Older Patients: Age > 11 yrsOlder Patients: Age > 11 yrs Large / Heavy Children Large / Heavy Children Comminuted Fractures Comminuted Fractures

Use Trochanteric Entry NailUse Trochanteric Entry Nail Piriformis Nail = Risk of AVNPiriformis Nail = Risk of AVN Violates Ascending Cervical Violates Ascending Cervical

ArteryArtery

Beware Rotational Beware Rotational Malalignment Malalignment

11 yo: Fell From 11 yo: Fell From SkateboardSkateboard

I want to…I want to…A.A. Take a closer look….something Take a closer look….something

seems funny about this fractureseems funny about this fracture

A.A. Treat this with traction until it Treat this with traction until it gets sticky then a single leg gets sticky then a single leg spica cast. That fracture is spica cast. That fracture is awfully high and he might need a awfully high and he might need a supplemental cast even if I fix it. supplemental cast even if I fix it.

A.A. Treat this with a submuscular Treat this with a submuscular plate. Locking plate technology plate. Locking plate technology is cool!is cool!

A.A. Treat this with flexible nails. Treat this with flexible nails.

A.A. Transfer this to an adult trauma Transfer this to an adult trauma center. Subtrochanteric fractures center. Subtrochanteric fractures are hard…let the adult guys do are hard…let the adult guys do it. it.

Take a closer look….Take a closer look….

CT Scan: Lytic Lesion CT Scan: Lytic Lesion

Differential Diagnosis?Differential Diagnosis?

What’s Your Plan?What’s Your Plan?A.A. Spica Casting. I Might do more harm than good Spica Casting. I Might do more harm than good

putting hardware into pathologic bone.putting hardware into pathologic bone.

A.A. Retrograde Flexible IM Nailing. This is a thin 10 year Retrograde Flexible IM Nailing. This is a thin 10 year old…perfect indication.old…perfect indication.

A.A. Open Biopsy and Flexible Nailing. I want to know Open Biopsy and Flexible Nailing. I want to know what this is while my flexible nails are holding perfect what this is while my flexible nails are holding perfect alignment. alignment.

A.A. Rigid IM Nailing. The fracture seems a little high for Rigid IM Nailing. The fracture seems a little high for flexible nails.flexible nails.

A.A. Open Biopsy and Flexible Nailing. Not every lytic Open Biopsy and Flexible Nailing. Not every lytic lesion is a Unicameral Bone Cyst…. lesion is a Unicameral Bone Cyst….

Open Biopsy and Rigid Open Biopsy and Rigid IM Fixation IM Fixation

Lesion: Firm Pink-Tan Rubbery Tissue Path: Fibrous Dysplasia

Open Biopsy and Rigid Open Biopsy and Rigid IM Fixation IM Fixation

Delayed Union / Non-Union (Rare)Delayed Union / Non-Union (Rare)

Limb Length DifferenceLimb Length Difference

Malunion / Deformity Malunion / Deformity

Re-fractureRe-fracture

COMPLICATIONSCOMPLICATIONS

Limb Length DiscrepancyLimb Length Discrepancy

7-10 mm Overgrowth Expected 7-10 mm Overgrowth Expected (children < 10 yrs)(children < 10 yrs)

Excessive Overgrowth PossibleExcessive Overgrowth Possible

Excessive Shortening Possible (Spica) Excessive Shortening Possible (Spica)

Inform Family Prior to TreatmentInform Family Prior to Treatment

RefractureRefracture Load-Bearing Devices:Load-Bearing Devices:

PlatesPlates External Fixators External Fixators

External Fixators:External Fixators: Through healed fracture site After Removal Through healed fracture site After Removal Through pin hole site After Removal Through pin hole site After Removal

Plates:Plates: In-Situ: Fracture at End of PlateIn-Situ: Fracture at End of Plate S/P Removal: Fracture Through Screw Hole S/P Removal: Fracture Through Screw Hole

13 yo (95 kg) Developmentally Delayed: 13 yo (95 kg) Developmentally Delayed:

Fell at HomeFell at Home

Lots of Options Right?

Submuscular PlatingSubmuscular Plating

4.5 LCDC Plate

But then this happened…But then this happened…

What’s your plan now?What’s your plan now?A.A. Let it heal where it is. He’s fat and the Let it heal where it is. He’s fat and the

deformity won’t be that noticeable.deformity won’t be that noticeable. A.A. Manually unbend the plate in the OR Manually unbend the plate in the OR

and apply a supplemental spica and apply a supplemental spica cast….tthe fixation is good so a cast….tthe fixation is good so a straighter plate means a straighter straighter plate means a straighter femurfemur

A.A. Put on a new plate. Do they make Put on a new plate. Do they make something bigger than 4.5?something bigger than 4.5?

A.A. Rigid IM Nailing. Still can’t believe Rigid IM Nailing. Still can’t believe they didn’t do this the first time….they didn’t do this the first time….

A.A. External fixation. This has to be the External fixation. This has to be the right answer at some point!right answer at some point!

Apply Circular Ex-FixApply Circular Ex-Fix

Remove PlateRemove Plate

Use Frame to Correct Use Frame to Correct Alignment Alignment

Varus Valgus

Allow WBAT and Knee ROM Allow WBAT and Knee ROM in Framein Frame

MalunionMalunion

Commonly Varus and ProcurvatumCommonly Varus and Procurvatum Preventable Preventable Spica Cast: Valgus MoldSpica Cast: Valgus Mold Appropriate Implant and Construct Appropriate Implant and Construct

Rotational MalunionRotational Malunion More Common with Transverse Fractures More Common with Transverse Fractures More Common in Older Children More Common in Older Children

Distal Femur Valgus DeformityDistal Femur Valgus Deformity Associated with SM Plating Associated with SM Plating Distal Fractures Distal Fractures Tethering of Lateral Periosteum?Tethering of Lateral Periosteum? Physeal Injury During Insertion? Physeal Injury During Insertion?

Other Problems Other Problems

Delayed Union / Non-Union:Delayed Union / Non-Union: Open Fractures Open Fractures Load Bearing ImplantsLoad Bearing Implants

Hardware Problems:Hardware Problems: IT Band Irritation from Prominent Nails IT Band Irritation from Prominent Nails May Result in Painful Knee ROM / StiffnessMay Result in Painful Knee ROM / Stiffness Can Occur with Distal Plates as Well Can Occur with Distal Plates as Well

QUESTIONS?QUESTIONS?