paediatric hip and femur fractures seminar by rv

PAEDIATRIC HIP AND FEMUR FRACTURESDR.RAVI VARMA.V.NMODERATOR-DR.MRUTHYUNJAYA

HIP FRACTURES•Very rare compared to adult hip fractures•Less than 1% of all pediatric fractures•80-90% due to high energy trauma

Difference from adults•Anatomy•Proximal femoral epiphysis is at a risk of

fracture•Smooth Fracture surfaces, with very little

interlocking impaction closed reduction less stable.

•Blood vessels to the femoral head are easily damaged, and a high incidence of AVN occurs in fractures in children than adults.

•Growth arrest in the physis can cause shortening of up to 15% of the total extremity

• Varus or valgus angulation of the femoral neck also can occur from arrest of only one side of the physis.

•A child can tolerate immobilization much more readily than an adult, and thus more choices for treatment are available, including traction, a spica cast, and bed rest, in addition to operative treatment.

•Fixation devices causes growth arrest.

Mechanism of injury•Severe High energy trauma•Always associated with other injuries-

careful evaluation is a must•Minor injury suspect pathologic

fractures(unicameral bone cyst,osteogenesis imperfecta,fibrous dysplasia,myelomeningocele,osteopenia due to polio)

Applied anatomy•Proximal femur has single physis at birth•Separates into two distinct centers of

ossification capital ephiphysis trochantric apophysis•Ossification of femoral ephiphysis

between 4 to 6 months•Ossific nucleus of greater trochanter

appears at 4 years

•Lesser trochanter at 10 years•Trochanteric physis growth arrest at 16-

18 years•Proximal femoral physis at 18 years•Neck shaft angle is 135 degree at birth•145 degree at 1 to 3 years •Gradually matures to 130 degrees at

skeletal maturity

•Femoral anteversion is 30 degrees at birth and ranges to 10.4 degrees at skeletal maturity

•Growth arrest causes abnormal neck shaft angle,femoral anteversion and a reduced articulotrochantric distance

•Mild limb length discrepency as it contributes approximately 15% of growth of extremity

Blood supply to proximal femur•Two major arteries medial circumflex(major) lateral circumflex•Extracapsular ring•Intracapsular ring•Lateral cirumflex supplies lateral and anterolateral of GT anteromedial of femoral head till 5 to 6 months anterolateral

physis

Profunda femoris

Medial circumfle

x

Posterior inferior

Posterior superior

Lateral circumfle

x

transverse

Ascending

descending

Medial circumflex is the major supply of proximal femur

•Travels posterior to iliopsoas tendon•Continues along medial side of femur

between inferomedial capsule and LTSupplies•Postromedial ephiphysis•Posterior physis•Posterior aspect of GTThe artery of ligamentum teres supplies

small area of femoral head(20%) continues to adulthood,branch of obturator(80%) or medial circumflex(20%)

•At 15 to 18 month blood vessels crossing physis gradually disappear

•By end of 3 years entire blood supply of proximal femoral ephyphysis from lateral ephiphysial vessels( br of medial circumflex)

•These vessels stay external at level of intertrochantric level

•Traverse the capsule within retinacular folds hence should be careful during capsulotomy

•This supply continues to adulthood

•Unique vascular supply to CFE makes immature hip vulnerable to growth derangement & subsequent deformity after a fracture.

DELBET CLASSIFICATION

•TYPE I : Transepiphyseal separation I A : With dislocation II B: With out dislocation.•TYPE II : Transcervical fracture•TYPE III : Cervicotrochanteric fracture.•TYPE IV : Intertrochanteric fracture.

TYPE 1-TRANSEPHIPHYSEAL•Acute traumatic separation of a

previously normal physis•<10% of peadiatric hip fractures•Similar to salter harris type 1•Differenciated from SCFE by age of

onset,onset of pain,severe trauma,more displacement

•More common in <2 years and 5 to 10 years

mechanisms•In a new born during a difficult breech

delivery [proximal femoral epiphysiolysis] mistaken with DDH.

•Following post reduction in post dislocation of hip

•High energy trauma•Child abuse

•Presentation is late•Associated with dislocation(50%)•Associated with other injuries•Result of treatment are poor

TYPE 2-TRANSCERVICAL• Fracture through mid

portion of neck• Most common 50% of

paediatric hip #• Severe trauma• 50% go to AVN as the

fracture is usually displaced at presentation

• Incidence of AVN related to initial displacement.

TYPE 3-CERVICO TROCHANTRIC• Fracture through the

base of femoral neck• 25-35% incidence• AVN 20-30%• Premature physeal

closure 25%.• Coxa vara 14%.

TYPE 4-PERITROCHANTRIC• Fracture between

greater and lesser trochanter

• 6-15% incidence• Lowest complication

rate• Good healing.• Nonunion & AVN

rare.

others•Proximal metaphyseal fractures in new

borns-confused with SCFE and dislocations

•Stress fractures-20 cases in literature

Clinical features•Severe pain/cry•Examine for associated injuries•Conversely look for hip fractures in other

injuriesOn examination•Injured limb in lateral rotation and adduction•If associated with dislocation classically

present with that deformity•Tenderness,painful movements•Be careful in non displaced fractures-limp

RADIOGRAPHY-X RAYS•AP and lateral views•Classify according to delbet•Look for displacement and ephyphysis•Trabecular pattern-Any Break or offset of

bony trabeculae near Ward’s triangle impacted #.

•Compare to the normal side

RADIOISOTOPE SCAN•Non displaced fracture and stress

fracture•Must be delayed after injury-for increased

metabolism(48-72 hrs)

MRI•Best for non displaced and stress

fractures•Better accuracy•Early diagnosis•No radiation•Shorter stay at hospital•Additional information of femoral head

viabilty,presence of bone cysts

TREATMENT•Age•Type•Displacement•Fracture lineRESULTS IN young(<8yrs),nondisplaced,type 3 and 4

are better thanolder,displaced,type 1 and 2

TYPE 1 TREATMENT•Due to high rate of complications•Anatomic reduction and rigid internal

fixation •Followed by cast immobilization is to be

followed

•Check for PFE if displaced out of acetabulum, if so,flex,slightly abducted and internally rotated under fluoroscopy guidance and closely reduced

•After reduction,internal fixation performed through lateral incision

<4 years-smooth krischner wires 4 to 7years-4.0mm cannulated screws older child-5.0 to 6.5 mm cannulated

screws

•A single attempt at closed reduction•Multiple attempts may predispose to AVN•Open reduction-mostly dislocated posteriorly

so modified southern moore approach to be done

if anterior smith peterson or watson jones approach to be used and fracture fixed internally

•Post fixation child is immobilized in one one and half hip spica cast with hip in neutral extension,30 degree abduction and 10 degree internal rotation

•Immobilized for 6 to 12 weeks•<2 years closed reduction and spica casting

alone can be done

TYPE 2-TREATMENT•Anatomic reduction & stable IF always

indicated to minimize risk of complications.

•Reduction by traction in extension and abduction and slight internal rotaion with downward pressure on GT and internal fixation as earlier by lateral approach

•Open reduction Watson & Jones approach

Sugical recommendations•Screws to be inserted short of physis.•If not good purchase penetrate the physis.•Treatment of # is priority, growth

disturbance & LLD are secondary•In older children 2 parallel screws must

be placed

TYPE 3 TREATMENT•Similar to type 2•Due to more distal fracture doesn’t afford

good purchase,hence casting has to supplement

TYPE 4 TREATMENT•Best outcome •Can be treated non operatively <6

years,regardless of displacement.•Indications for Internal fixation - failure to maintain reduction - polytrauma - older children

SURGICAL TIPS•Always predrill & tap before inserting

screws.•Avoid crossing the physis but cross it if

necessary for stability.•Postop, hip spica for 6-12 wks if < 10 yrs,

Stess fractures• Repetitive cycle loading of hip by new or

increased activity, in a pathologic or normal bone• Adolescent female athlete, anorexia nervosa, &

osteoporosis.• X rays only reveal after 4-6 wks• DEVAS classification1. Compression - non wt bearing, coxa vara. 2. Tension – inherently unstable, insitu fixation

• Can be managed conservatively• Non wt bearing• Cast in non cooperative child• Weight bearing only after complete radiological

union

COMPLICATIONS1. AVN2. COXA VARA3. NON UNION4. PREMATURE PHYSEAL ARREST5. INFECTION

AVASCULAR NECROSIS•Most serious & most frequent•Overall prevalence 30%.•Primary cause of poor results.•Highest in type I>II> III>IV•Initial # displacement, damage to blood

vessels, # hematoma are the factors

PREVENTION•Early treatment•Aggressive operative management•Decompressive hip arthrotomy-needle

aspiration(subadductor approach) followed by internal fixation of fracture

Clinical features and radiology•Early pain in the groin•Radiological features seen as early as 2

monthsFeatures•Osteopenia of femoral head•Followed by sclerosis,fragmentation,often

collapse and deformityMRI is most sensitive and confirms the

diagnosisRADIOISOTOPE scanning with steel

implant-decreased uptake

RATLIFF CLASSIFICATION•TYPE I : Involvement of whole head - most severe & most common form - worst prognosis -damage to all lateral epiphyseal

vessels•TYPE II: Partial involvement - localized damage to one or more

LEV.•TYPE III: an area of AVN from # to physis - damage to superior metaphyseal V. - rare but good prognosis.

TREATMENT AND PROGNOSIS•Treatment is unsuccessful•Limited data available hence defining the

superior modality is difficultGOALS OF TREATMENT•Preserve the functional range of hip•Maintain containment of femoral head in

acetabulum•Preserve as much as femoral head

viability as possible

•Treatment should begin at the onset of symptoms and should stress on non weight bearing or partial weight bearing

•Operative-1st is to remove the implant Intertrochantric valgus osteotomy Core decompression with fibular grafting Capsulotomy Arthrodesis Arthroplasty

Coxa varaCauses•Malreduction•Loss of reduction•Delayed and non union•Premature closure of ephiphysis(GT

overgrowth)Incidence 10-32%•Highest in closed reduction and external

immobilization•Lesser in internally fixed

•Obliquity of fracture(pauwels angle <50 degree)

•< 100 degree of neck shaft angle and older children have high incidence of varus

Preventive measures•Internal fixation with cast immobilization•Avoid screw crossing growth plateTREATMENT•Valgus osteotomy(subtrochantric valgus

osteotomy)

NON UNION•Incidence 6.5%-12.5%•Poor reduction•Distraction of fracture fragments•Time of internal fixation•Pauwels angle >60 degreeNon union can lead to other complicationsPrevention by means of anatomic

reduction,internal fixation and external immobilization is important

treatment•<10 years autogenous bone grafting and

rigid internal fixation in lag fashion•Older child subtrochantric valgus

osteotomy-goal is to alter plane of fracture to produce compressive loads across fracture site and followed by blade plate fixation

PREMATURE PHYSEAL ARREST•Incidence 10-62%•Amount of displacement at time of injury•The development of AVN•Internal fixation crossing physis•More number of pins for fixationNo significant deformity or limb length

discrepencyBut if combined with AVN causes it in all

cases

Preventive measures•Gentle closed reduction•Smooth pin fixation in young child and

cannulated screws not crossing physis(fracture stability not compromised)

•Serial scanograms and bone age measurements done to predict limb length discrepency

•Moseley line graph used to accurately predict timing of contolateral ephiphysodesis

INFECTION•Very rare 1%•Associated with AVN•Treatment –debridement,IV antibiotics

FEMORAL SHAFT FRACTURES

ANATOMY AND DEVELOPMENT•Femur appears at 4th week of gestation•8th week enchondral ossification begins•Primary center is femoral shaft•Secondary center proximally at 6 month•Distal secondary center at 7th fetal month•The femur shaft grows initially by enchondral

ossification•Production of medullary cavity with

calcification in the periphery and vascularization in center results in a large primary ossification center

•Woven bone for 18 months later lamellar type

•Blood supply is from both endosteal and periosteal blood vessels

•Endosteal derived from two nutrient arteries enter femur from posteromedial direction

•Periosteal supply outer 25% of cortical bone more near muscular attachments

•Two systems with metaphyseal complex interconnected to provide strong supply,hence rapid fracture repair

Mechanism of injuryAge dependent•Child abuse before walking age 70% Appropriate examination,rule out other

injuries,later presentation

•Adoloscent –high velocity injury waddles triad-femur fracture with

head and thoracic injuries

Differnces from adult•Pulmonary complications are rare with

multiple injuries and timing of intervention doesn’t affect

•Minor trauma should alert pathology(osteogenesis imperfecta,osteopenia of cerebral palsy,myelomeningocele,aneurysmal bone cyst,unicameral bone cyst very rarely ewings and malignancies

CLASSIFICATION•WINQUIST AND HANSEN

CLASSIFICATION

Fracture discription•Condition of soft tissue•Location of fracture•Configuration•Angulation•Shortening- >3cm is unacceptable•Winquist helps in classifying

communition-useful in nailing

Clinical features•Localised tenderness,crepitus,abnormal

mobility and deformity•Look for ecchymosis around hip to rule

out ipsilateral and contolateral hip fractures

•Neurologic and vascular examination(rare)

Radiology•AP and lateral views of entire

femur,hip,knee•Thomas splint manipulated and xray

taken•Look for fracture

pattern,diplacement,communition•Stress fractures need CT and MRI

evaluation•Intraarticular fractures and dislocation

needs CT•angiography

TREATMENT•Result of high energy trauma•Multidisciplinary team approach

necessary•Age,mechanism,diplacement,soft

tissue,social life

TREATMENT OPTIONS• Traction• Spica Casting• Pins & Plaster• External Fixation• Internal Fixation

▫Plate/Screws▫Flexible nails▫Rigid Intramedullary rods - trochanteric

vs. lateral entry

• Treatment is often directed by the patient’s age

▫0-6 months▫6 months - 5

years▫5 - 11 years▫11 years -

skeletal maturity

0 - 6 Months•40% of femoral diaphyseal fractures in

patients <1 year of age are non-accidental

•Child Abuse - >90% of pediatric femoral shaft fractures resulting from abuse occur in children <36 months of age

0-6 months• Pavlik harness

▫Stable union typically achieved within 5 weeks

• Spica casting▫Higher risk of skin complications than

Pavlik▫Waterproof cast liners improve sanitation

• Spica casting with incorporated distal femoral traction pin

▫May decrease incidence of unacceptable shortening and frontal plane malalignment

6 months to 5 years▫Diaphyseal Femur

Fractures: <2cm shortening

Early spica casting (90°/90°)▫Enhanced ease of care▫Shorter hospital stay▫No defined optimal weight range

Traction with delayed spica casting▫Skin traction typically ineffective; skeletal traction often required

• Diaphyseal Femur Fractures:▫> 2cm shortening

Spica casting Insufficient evidence to recommend

for/against (AAOS Clinical Practice Guideline)

External fixation Lower incidence of malunion

compared to spica casting Flexible IM nailing may be considered

for the oldest, most mature patients in this age group

• Insufficient evidence exists to recommend any specific degree of angulation, rotation, or shortening that is unacceptable (AAOS Clinical Practice Guideline)

▫Traditionally: Varus/valgus deformity more poorly

tolerated than flexion/extention deformity Up to 30° of rotational malunion can be

tolerated Remodelling occurs to a greater extent in

younger children with more growth potential

Overgrowth is a biologic response to fracture in this age group but is unpredictable

5-11 YEARS• Skeletal Traction

▫Typically used to precede definitive treatment particularly in severely traumatized patients

• Spica casting▫Poorly tolerated, ▫Higher risk of malunion

Flexible (Elastic) Intramedullary Nails

▫ Preferred method for treatment of most femoral disphyseal fractures in this age group

▫ Load sharing capability▫ Titanium or stainless steel (Enders)▫ Antegrade or retrograde (more common) insertion▫ Outcomes best when used to treat stable fracture patterns▫ Shorter hospital stay▫ Fewer adverse events▫ More rapid return to school▫ Most common complication is irritation at distal insertion

sites

•Avoids more proximal insertion and thus avoids AVN

•Used in 6 to 16 years though used<4 years

Procedure-•2 flexible nails of equal diameter should

be used to allow 3 point fixation•A single entry point is used laterally with

c shaped rod ending in metaphyseal region of GT and s shaped ending till mid portion of neck

•Should be kept till union is seen radiologically

•Removed within a year as removal becomes difficult later

11 YEARS TILL MATURITY• External Fixation

▫ Useful to achieve provisional fixation of femoral fractures in severely injured patients or open fractures

▫ May be used for definitive treatment of subtrochanteric or distal metadiaphyseal fractures that are less amenable to plate or nail fixation

▫ Avoids direct fracture exposure, minimizes blood loss, minimizes risk of physeal injury

▫ More frequent complications include delayed union,pin tract infections and refracture after device removal

•Compound fracture•Disruption of tissue•Multiple trauma•Arterial injury•Unstable pattern•Failed conservative management

• Flexible intramedullary nails▫Outcomes optimized when use is limited to

stable fracture patterns▫Higher risk of complications in patients

>11 years of age, >108 lbs (49kg), and unstable fracture patterns

▫Commonly reported complications: knee pain at insertion site, nail prominence, nail migration, fracture shortening/malunion, delayed union

Submuscular plating• Limited approach with indirect fracture reduction• Useful in communited fracture and unstable

fractures• 12-16 holed lcp inserted submusculary and

superficial to periosteum through 2 cm incision over proximal and distal metaphyseal flare

• Reduced by traction and unstable portion is bridged

• Under fluroscope,screws placed percutaneously by stab incision

•Union by 12 weeks•Technically demanding

• Rigid intramedullary nailing - greater trochanteric entry femoral nail

▫Well suited for unstable fracture patterns▫Patients >108lbs (49kg) who are not

candidates for flexible IM nailing▫Piriformis or near-piriformis entry nailing is

NOT a treatment option Risk of injury to the lateral ascending

cervical branches of the medial femoral circumflex vessel in the piriformis fossa

Increased risk of femoral head osteonecrosis (≥4%)

▫Risk of coxa vara due to trochanteric apophyseal growth arrest

▫Permits rapid mobilization

• Rigid intramedullary nailing- lateral entry femoral nail

▫Similar indications to trochanteric entry nails

▫Designed to avoid injury to circumflex vessels and trochanteric apophysis

TREATMENT TECHNIQUESSKIN TRACTION-•Non invasive used in 2 situations small child with shortening >3cm to allow

spica casting child who is to undergo definitive skeletal

fixation on a delayed basis•Bryant’s traction <2 years-overhead traction

with hip in 90 degree and knee extendedVascular insufficiency is a common complication,

Skeletal traction-•Older child with diaphyseal fracture when

more than 5-10lb weight required•Distal femur is the best site parallel to

knee•If soft tissue injury then at proximal tibia

after ruling out knee injuriesTraction should reduce within 2 cm in

younger child and end to end in older child

Continued till callus formation 2-3 weeks

Spica casting•Immediate casting advised in•Stable shaft fracture•<3mm shortening•<8years•Without massive swellingIf not a period of traction used

•The cast should be placed with child's hip flexed approximately 60-90 degrees(the more proximal fracture more is to be flexed)

•30 degrees of abduction•Knee flexed to 90 degrees•Some external rotation will correct the deformity•Applied on a spica table•Applied when assistant holds fracture in

reduction•Take care of compartment syndrome

•Radiographs taken before hardening for manipulation

•Acceptable alignment depends on age•Not more than 15 degree deformity in

coronal plane•And 25-30 degree in sagittal plane•Shortening not >2cm•Serial radiographs•Wedging for correction of angular

deformity

COMPLICATIONS•Limb length inequality•Unacceptable angulation•Rotational deformities•Non union and delayed union•Compartment syndrome•Infection inflammation•Vascular injury

Limb length inequality•Due to overgrowth or shortening at

fracture site•Due to this ideal reduction should have

1.5 to 2cm shortening•Treatment of excessive shortening

depends on time of recognition•Hip spica to be removed re traction and

application•If callus has formed osteoclasis followed

by external fixation

angulation•Depends on•Age•Proximity of fracture to physis•Plane•Younger children,fracture near physis and

deformity in the plane of motion good remodeling potential

•25 degree acceptable•If significant, corrective osteotomy close to

apex of deformity and rigid fixation is done

ROTATIONAL DEFORMITIES •Have less remodeling than angular•15 to 25 degree well tolerated•Most severe require corrective surgery

NONUNION AND DELAYED UNION•Very rare •Nonunion treated by bone grafting with

rigid fixation•Delayed union external fixator with

dynamization

COMPARTMENT SYNDROME•Very rare in thigh to to high muscle mass•Risk factors in prolonged Bryant's

traction,direct trauma•fasciotomyINFECTIONINFLAMMATION VASCULAR INJURY

DISTAL FEMORAL INJURIES

ANATOMY•Formed from single ossific nucleus, first

present at birth and is first epiphysis in body to ossify

•Grows at a rate of 8-10 mm per year•Contributes 40% of growth of lower

extremity•Closes at 13 in girls and 15 in boys

•The distal femur has a classic rhomboid shape and inclination of joint line at knee

•Anatomic axis-9 degree•Mechanical axis-3 degree

•The muscular attachment of gastrocnemius and plantaris is on posterior aspect of distal femoral metaphysis,proximal to physis,hence flexion

•Adductor magnus attached to medial aspect of femoral metaphysis,hence varus

•Collateral ligaments attach at the level of epiphysis

Mechanism of injuryAGE•Newborn period-breech presentation-type

1 SA •In 3-10 years, severe trauma, rarely

sports injuries•In adolescents more of sports injuriesDIRECTION OF FORCE•Valgus type of force•Hyperextension force

CLASSIFICATION

CLINICAL FEATURES•Acute distress secondary to pain•Knee is in flexed position•Deformity•Ecchymotic areas indicate deforming

forces•Look for swelling in popliteal region•Neurovascular examination is the must

radiology•Xrays•Stress views•ct•Mri •Ultrasound•X-rays should be compared with

contralateral physis

TREATMENTDISTAL FEMORAL METAPHYSEAL

FRACTURE•Closed reduction,percutaneous pinning

and cast conversion is preferred•Anatomical reduction with acceptable

residual angulation in sagittal plane 20 degrees <10 degree in child

•No rotational misalignment accepted•<5 degree varus and valgus

External fixation•Soft tissue injury with open fracture•Poly trauma patient with urgent

satbilizaation•Highly communited fracture •Fracture is reduced primarily•With two pins proximal to fracture site and

two pins in the distal metaphyseal fragment• Placed atleast 1cm away from physis and

parallel to knee joint line from lateral•And fluoroscopically checked in extension

and realigned if any malalignment

•Partial Weight bearing started depending on the stability

•After mature callus is formed immobilzed in walking cast or dynamization of ex fix done

•With highly communited fracture spanning of knee joint with 2 pins 3cm distal to tibial tubercle,

•In such case tibial pins to be removed to allow knee rom after 4 to 6 weeks

CLOSED REDUCTION AND INTERNAL FIXATION

•hyperextension type of injury-distal fragment is flexed by pull of gasrtocnemius and proximal fragment is posteriorly placed

•Hyperflexion type-distal fragment is flexed and proximal fragment is anterior

• Reduction is difficult as plane of motion and plane of displacement in same direction

• And inadequate lever arm of distal fragmentHyperextension type-hip and knee flexed to relax

quadriceps and hamstrings• Longitudinal traction applied with increasing

flexion of knee to bring distal fragment posteriorly• Distal fragment pushed posteriorly and proximal

fragment anteriorly• With knee flexed to 60 degree and reduction

checked

•Hyperflexion type-axial traction with knee in extension,posterior distal fragment pushed anteriorly and proximal fragment posteriorly

•Once reduction achieved 2 threaded pins placed in cross fashion as far as from physis

•And external immobilization with spica cast hip in 60 degree or long leg cast with hip in 30 degree flexion depending on stability

•Knee in 60 degree flexion for 2-3 weeks and bought to extension later

OPEN REDUCTION AND INTERNAL FIXATION

•Irreducible•Require stable fixation such as arterial

injuryM0st common reason for failure is proximal

fragment buttonholing of the quadricepsStandard lateral approach , if arterial

injury then medial approach

DISTAL FEMORAL PHYSEAL FRACTURESTREATMENT PRINCIPLES•All attempts to closed reduction to be

performed under GA or sedation•Reduction maneuvre,predominantly traction

followed by manipulation•Not be performed for >10 days injury•Anatomic reduction to be achieved

especially in type 3 and 4•Internal fixation should avoid physis and

should be non threaded if crossing physis

NOTE- salter and colleagues stated that when excessive ,manipulation appears to be necessary to achieve acceptable reduction,it is better to maintain growth potential and perform corrective osteotomy at a later date than overstress to physis

SA TYPE 1•New born treated by immobilization-

remodelling•Older child closed reduction with

immobilization with cast•Older child with unstable requires smooth

pins or wires removed at 4 weeks and immobilized further

SA TYPE 2•75% are displaced more in juvenile•Non displaced and mildly displaced

fracture successfully treated by closed reduction and immobilization

•With reduction under GA and mainly traction and followed by reduction of angulation with a cast long leg in knee 30 degree extension

•With ligament injury reduction not tried and requires internal fixation

•Displaced type closed reduction under GA with percutaneous fixation of metaphyseal fragment with k wires/ccs

•Followed by immobilization in long leg cast in knee 30 degree flexion

•If closed reduction fails due to periosteal or muscle interposition open reduction planned

SA TYPE 3•Usually displaced and rare•Requires open reduction an internal

fixation•Followed by immobilization with knee in

30 degree flexion•Anatomical reduction to preserve

articular surface

SA TYPE 4•Similar to type 3•Both metaphysis and epiphysis should be

fixed

PROGNOSIS•Of these fractures depends upon •Age •Displacement(strong predictor)•Adequacy of reduction and fracture

stabilization•Type of fracture•Type 1 and 2 have better outcome

complicationscomplicatio

ns

acute

Arterial injury

Peroneal nerve injury

Ligamnetous injury

Loss of reduction

late

Physeal arrest

Angular deformity

Loss of knee motion

ARTERIAL INJURY•Rare in distal ephiphyseal injury•Common in complete separation of physis

in a hyperextension injury•Injury to the arterial wall only 3 cases

reported•Hence after reduction in case of

discrepency btw two limbs pulse is checked

•Arterial injury requires stable fixation via medial approach

•Fasciotomy if needed

Peroneal nerve injury•Direct trauma on posterolateral aspect of

leg•Varus producing injury causing over

stretching•All injuries resolve by 6 month period •If no improvement for 3 months NCV to

be done and explored and nerve grafting or direct repair

Ligamentous injury•Most commonly involved is ACL followed

by LCL then MCL•Even meniscal injury possible• it is difficult to diagnose at time of injury

and should be evaluates soon after union

Loss of reduction•Due to suboptimal stabilization of

unstable fracture•Not immobilized in cast•No flexion in anteriorly displaced •No extension in posteriorly

Physeal arrestRisk factors•High energy trauma•Juvenile age group•Severly displaced fractures•Communited fractures

•Physeal fractures thoroughly evaluated by CT

•Physeal bar resection when <50% physis is involved and the growth remaining is atleast 2.5cm

•Limb lengths should be plotted on moseley straight line graph over a 1 to 2 year period to determine the projected discrepency at skeletal maturity

•No treatment is indicated if <2cm of discrepency

•Between 2 to 6 epiphyiodesis of contralateral distal femur or proximal tibia

•Large discrepency should be treated by femoral lengthening procedure

ANGULAR DEFORMITY•Less seen than limb length discrepency•Risk factors and indication for physeal bar

resection are the same•Treatment indicated >5 degree of

abnormal angulation is present consists of angular corrective osteotomies or ephysiolysis

Loss of knee motion•Excessive duration of immobilization•In SA type 3 and 4 due to articular

incongruitiesPrevented byRestricting the duration of immobilizationRemoving k wires as soon as possibleanatomic redution of intrarticular fractures

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