Download - 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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Femoral Shaft Fractures
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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Femoral Shaft Fractures
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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Femoral Shaft Fractures
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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Distal Femur Fractures
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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Distal Femur Fractures
Treatment Basic Principles
Anatomic reduction
PhysesArticular surfaces No step-off,
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Distal Femur Fractures
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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Distal Femur Fractures
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Distal Femur Fractures
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
Distal Femur Fractures
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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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Distal Femur Fractures
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Distal Femur Fractures
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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Distal Femur Fractures
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