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Fractures of the Femoral Shaft in the Pediatric Patient

Fractures of the Femoral Shaft in the Pediatric Patient. Steven Frick, MD Original Author: Brent Norris, MD; March 2004 New Author: Steven Frick, MD; Revised August 2006. Pediatric Femur Fractures. 1.6 % all children's Fx’s 28/100,000 child years (Holland) 3:1 Male / Female ratio

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Fractures of the Femoral Shaft in the Pediatric Patient

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  1. Fractures of the Femoral Shaft in the Pediatric Patient Steven Frick, MD Original Author: Brent Norris, MD; March 2004 New Author: Steven Frick, MD; Revised August 2006

  2. Pediatric Femur Fractures • 1.6 % all children's Fx’s • 28/100,000 child years (Holland) • 3:1 Male / Female ratio • Children >3 y.o.- highest incidence • Seasonal- highest summer

  3. Treatment Goals - Restore • Length • Alignment • Rotation

  4. Treatment Goals - Avoid • Osteonecrosis - disruption of blood supply to femoral head • Physeal injury- preserve future growth potential (proximal and distal femoral physes, trochanteric apophysis)

  5. Anatomy and Growth • Proximal femoral physis- 30% of longitudinal growth • Distal femoral physis- 70% of longitudinal growth • Trochanteric apophysis- most of trochanteric growth appositional after age 8 years

  6. 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 Chung S. JBJS 58A, 1976

  7. Pediatric Femur Fractures-Mechanism of Injury • Rule out NAT in children <1year old • Falls- young children/toddlers • Struck by car- juvenile • Recreational sports/activities- adolescent • Motor vehicle crashes- all age groups

  8. Mechanism of Injury • Low Energy • High Energy • predicts behavior/treatment of the fracture (Blount-1973, Pollack-1994)

  9. Pediatric Femur Fractures- Associated Injuries • Struck by car- triad of femur fracture, torso injuries, head injury • Potential damage to physes 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

  10. Spasticity Leading to Extreme Angulation and Shortening

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

  12. Radiographic Evaluation • AP Pelvis • AP/Lat femur • Visualize hip & knee joints

  13. Classification • Open or closed • Location of fracture- subtrochanteric, diaphyseal (proximal, mid, distal third), supracondylar • Fracture pattern- transverse, spiral, oblique, comminuted, greenstick • Amount of shortening • Angular deformity

  14. 7 Principles Dameron & Thompson JBJS 1959 • 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

  15. Dameron & Thompson JBJS 1959 • 5. Restoration of alignment more important than fragment position • 6. Overtreatment usually worse than undertreatment • 7. Immobilize/splint injured limb before definitive treatment

  16. Decision Making • Age • Mechanism of injury • Fracture pattern & location • Associated Injuries • Surgeon preference

  17. Traction Techniques • Skin or skeletal • Avoid physes if place skeletal traction pins • Place pin perpendicular to shaft to avoid varus/valgus angulation • Longitudinal in line traction for comfort prior to definitive treatment • Split Russells traction (90-90) if awaiting early healing prior to casting

  18. Immediate or Early Spica Cast-Ideal Patient • Less than 5 years old • Less than 100 lbs • Initial shortening not excessive • Isolated injury • Note -Spica casts used for decades and can work for almost any pediatric femur fracture

  19. Spica Cast Technique • 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 (>10-20° varus/valgus, >15-30° procurvatum/recurvatum – age dependent)

  20. Immediate Spica Cast • Fiberglass lighter, easier to x-ray through • Often strong enough to obviate need for connecting bar • See Kasser AAOS Instructional Course Lectures Volume XLI, 1992

  21. Immediate Spica Cast • 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

  22. Compartment Syndrome Complicating Early Spica Cast Treatment of Isolated Femoral Shaft Fractures in Children- JBJS Nov 03

  23. Early Sitting Spica – 3 Part, Below Knee Cast First Method, 90-90 Position This technique, recommended in textbooks and articles, may increase risk of developing compartment syndrome, and is not recommended

  24. Current Technique – Above knee cast (thigh and leg) first. Hip and knee- 40-45 flexion, foot out. Can include opposite thigh if desired. Unilateral spica cast effective for low energy fractures- see H. Epps, J Pediatr Orthop 2006

  25. AAOS Managing Orthopaedic Malpractice Risk 2000 • 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.

  26. Mold into slight valgus desired on initial radiograph after casting

  27. Femoral Remodeling after Fracture • 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

  28. Surgical Options • Plate & screw fixation • External fixation • Flexible nailing • Rigid nailing

  29. ORIF with Plates/Screws • Advantages – rigid, technique familiar to most surgeons, allows early motion, favorable results reported in children with associated head injuries • Disadvantages- large scar, possible refracture after plate removed, higher infection rate in some earlier series

  30. ORIF Plate Fixation

  31. External Fixation • Advantages – can be applied rapidly, allows soft tissue injury management , early mobilization, avoid cast • Disadvantages- pin site sepsis, pin site scarring, refracture, malunion

  32. 11 yo male MVC Pelvic fracture, ruptured bladder External fixation

  33. Ex Fix Fracture at Prox Pin Keep pin diameter <20% of bone diameter.

  34. Ex Fix Refracture 6 months post injury

  35. External Fixator Tips • Appropriate size half pin diameter • Proper pin placement relative to fracture for biomechanical rigidity • Do not remove ex fix until see bridging cortices (3 or 4 of 4)

  36. Open Femur FracturePrinciples • IV antibiotics, tetanus prophylaxis • emergent irrigation & debridement • skeletal stabilization • External fixation best option with severe soft tissue injury • soft tissue coverage

  37. Open Fractures Can use temporary shunting to restore distal perfusion during debridement

  38. Flexible Nailing • Advantages – allows early mobilization without cast, cosmetic scars, avoids physes and blood supply to femoral head • Disadvantages – later nail removal, ends may irritate soft tissues, may not be amenable to some fracture patterns (very proximal or distal, comminution)

  39. 12 yo male in ATV accident Closed proximal third, oblique Back at school 2 weeks Walking at 8 weeks

  40. Titanium Elastic Nailing - ResultsFlynn et al. JPO Jan 2001 • 57/58 excellent or satisfactory • No rotational malunions • 6/58 – 1-2 cm LLD

  41. Titanium Elastic Nailing - ComplicationsFlynn et al. JPO Jan 2001 • 5/9 proximal fx - > 5 degree angulation • 1 refracture after nail removal • 4/58 prominent nails – 1 premature removal • 1 poor result – 11 yo, 15 mm short, 20 degrees varus

  42. Titanium Elastic Intramedullary Nailing of Pediatric Femur Fractures:Predictors of Complications and Poor Outcomes Multicenter Study Launay, Flynn, Moroz, Frick, Kocher, Newton, Sponseller 2004 POSNA, OTA meetings JBJS – Br 2006

  43. Materials and Methods • Surgeons at 6 pediatric trauma centers • Consecutive series of femur fractures treated with 2 retrograde titanium nails • Analysis of complications

  44. Cohort • 234 femoral shaft fractures in 229 patients • 114 complications in 87 cases

  45. Results • Excellent in 148 cases (64%) • Satisfactory in 59 cases (26%) • Poor in 23 cases (10%)

  46. Most Complications – Minor Nail Irritation (16%) - don’t bend ends- all resolved post removal

  47. Cut Pins above Physis with Screw Cutter

  48. Major Complications – Reoperation or Unresolved Perioperative Problems23 Patients • 17 malunions • 9 loss of reduction • 5 limb length discrepancy • 2 deep infections • 2 refractures after nail removal • 2 protruding nails • 1 hematoma

  49. TEIN Yielded Excellent or Satisfactory Results in 90% of Cases

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