pediatric femur fracture

8/19/2019 Pediatric Femur Fracture

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Pediatric Femur FracturesPediatric Femur Fractures

Dr. MAMDOUH MASRIDr. MAMDOUH MASRI

&&

Dr. MahDr. MahJAN 25/2006JAN 25/2006



Pediatric Proximal Femoral FracturesPediatric Proximal Femoral Fractures

•• Proximal femoral epiphysisProximal femoral epiphysis13% overall growth in13% overall growth infemoral lengthfemoral length

•• GT apophysis damageGT apophysis damage

before 8yo causes shortbefore 8yo causes shortGT and coxaGT and coxa valgavalga abdabdlurchlurch

•• Metaphyseal andMetaphyseal andEpiphyseal blood supplyEpiphyseal blood supplyseparate until 14separate until 14--17yo17yo

•• Lateral femoral circumflexLateral femoral circumflex

(LFC) important until 6yo(LFC) important until 6yo

•• Lat EpiphysealLat Epiphyseal A.(posterosuperior A.(posterosuperior andand

posteroinferior posteroinferior arteries)arteries)supplies FH for rest of lifesupplies FH for rest of life(terminal(terminal br.MFCbr.MFC))



Proximal Femoral FracturesProximal Femoral Fractures

Proximal femur fractures are rare (1% ofProximal femur fractures are rare (1% of

all femur fractures)all femur fractures) High incidence of associated injuries (highHigh incidence of associated injuries (high

energy)energy)



DelbetDelbet Classification of ProximalClassification of Proximal

Femoral FracturesFemoral Fractures

Type 1* Transepiphyseal

Type 2* Transcervical (similar to subcapital)

Type 3* Cervicotrochanteric (similar to basicervical)Type 4 Intertrochanteric

* = orthopaedic emergency if displaced



Treatment (Based onTreatment (Based on DelbetDelbet

Classification)Classification)



TreatmentTreatment

DelbetDelbet I, II, and IIII, II, and III are usually treated with anare usually treated with an

operation because of the high rate of AVNoperation because of the high rate of AVN smooth pins forsmooth pins for DelbetDelbet II

22--3 cannulated screws short of physis for3 cannulated screws short of physis for

DelbetDelbet II and IIIII and III

DelbetDelbet IVIV Rx is broken down by age groupRx is broken down by age group

<6yo<6yo CR / immediate SpicaCR / immediate Spica 66--12yo12yo Traction x 3Traction x 3--4/52 & delayed Spica4/52 & delayed Spica

>12yo>12yo Pediatric DHSPediatric DHS



Closed reductionClosed reduction

GentleGentle Abd/longtitudinal Abd/longtitudinal traction starting intraction starting in

ERER IR (to lock) on fracture tableIR (to lock) on fracture table Document reduction/stability with ImageDocument reduction/stability with Image

(compare to other side)(compare to other side) Anatomic reduction mandatory or open Anatomic reduction mandatory or open

reductionreduction



Open ReductionOpen Reduction

WatsonWatson--Jones gluteus med. And TFL thenJones gluteus med. And TFL then

Glut med. and rectusGlut med. and rectus T capsule off acetabulum to preserveT capsule off acetabulum to preserve

blood supplyblood supply Gentle anatomic reduction +/Gentle anatomic reduction +/-- k wire ask wire as

joystick in femoral head joystick in femoral head

Percutaneous fixation (screw)Percutaneous fixation (screw)

Document reduction with imageDocument reduction with image



Capsular DecompressionCapsular Decompression

ControversialControversial some suggest formalsome suggest formal

capsulotomy even if closed reductioncapsulotomy even if closed reductionsuccessful via needle decompression orsuccessful via needle decompression or

sliding scissors/cobb along anterior necksliding scissors/cobb along anterior neck

thru mini lateral approach used for screwsthru mini lateral approach used for screws



Post opPost op

Hip Spica duration based on age:Hip Spica duration based on age:

age 6age 6 66--8 wks, age 128 wks, age 12 88--12 wks12 wks

If no spica, NWB x 4 wks post fixation toIf no spica, NWB x 4 wks post fixation to

allow for early healingallow for early healing Hardware removal @ 4Hardware removal @ 4 – – 6 months6 months

(screws) and 6(screws) and 6 – – 12 months (DHS) to12 months (DHS) todecrease stress riser and fracture riskdecrease stress riser and fracture risk

Yearly F/up complication checkYearly F/up complication check



A 6-year-old boy was struck by an automobile and sustained

a displaced type III fracture.



Complications & ManagementComplications & Management



Complications & ManagementComplications & Management Complications Tell parentsComplications Tell parents preoppreop!!

I.I. AVN AVN

Appears earlier than in adults (within 6 weeks) Appears earlier than in adults (within 6 weeks)

Ratliff ClassificationRatliff Classification

I Complete head involvementI Complete head involvement poor prognosispoor prognosis

II Physeal involvementII Physeal involvement minimal head collapseminimal head collapse

III NeckIII Neck

area from fracture line to platearea from fracture line to plate




No specific treatment earlyNo specific treatment early ObserveObserve

Head collapse with fracture unionHead collapse with fracture union earlyearlyremoval of hardwareremoval of hardware

Maintain ROM withMaintain ROM with physio/NSAIDs/softphysio/NSAIDs/soft tissuetissue

releasesreleases

If loss of containment or contracturesIf loss of containment or contractures

femoral/ acetabular osteotomyfemoral/ acetabular osteotomy




II.II. Growth ArrestGrowth Arrest

Fracture rarely causesFracture rarely causes LLdLLd > 2 cm as> 2 cm asproximal femoral physis contributes <proximal femoral physis contributes <

15 %15 % Must follow with routineMust follow with routine scanogramscanogram andand

plot on growth charts to determine finalplot on growth charts to determine final

LLD and plan any intervention ifLLD and plan any intervention if

significant e.g. Distal femoralsignificant e.g. Distal femoral

epiphyseodesisepiphyseodesis (normal leg) if projected(normal leg) if projectedLLD > 1.5cmLLD > 1.5cm




III.III. NonunionNonunion

Rare but requires early interventionRare but requires early intervention(unlike AVN)(unlike AVN)

Often Varus neck so ValgusOften Varus neck so Valgusintertrochanteric osteotomy to improveintertrochanteric osteotomy to improve

compression +/compression +/-- bone graft +/bone graft +/-- hip spicahip spica

cast post opcast post op




IV.IV. Coxa varaCoxa vara

Limited remodeling potential except in youngLimited remodeling potential except in youngpatientspatients

Indications for VITO : Age > 8, neck shaftIndications for VITO : Age > 8, neck shaft

Angle < 110, and coxa vara has been Angle < 110, and coxa vara has beenpersistent for more than 2 yearspersistent for more than 2 years

Preop plan closing wedge osteotomy @ levelPreop plan closing wedge osteotomy @ levelof lesser trochanter and fix with compressionof lesser trochanter and fix with compression

screw Post op spica x 8screw Post op spica x 8 – – 12 weeks12 weeks




greater trochanter overgrowthgreater trochanter overgrowth

treat withtreat with distal transfer of GTdistal transfer of GT -- best tobest todo once patient stops growing,do once patient stops growing,

otherwise problem may recur otherwise problem may recur

avoid GT epiphysiodesisavoid GT epiphysiodesis -- usuallyusually

unsuccessful because GT will continueunsuccessful because GT will continue

to grow by appositional growthto grow by appositional growth



Stress Fractures of FemoralStress Fractures of Femoral

NeckNeck Superior neck (tension type) Early ORIFSuperior neck (tension type) Early ORIF

with cannulated screws to prevent varuswith cannulated screws to prevent varusdisplacement/nonuniondisplacement/nonunion

Inferior neck (compression)Inferior neck (compression)Observe/activity modification/non wtObserve/activity modification/non wt

bearingbearing



Femoral Shaft FracturesFemoral Shaft Fractures

1.6% of all children1.6% of all children’’s fracturess fractures

2.6 : 1 (male/female)2.6 : 1 (male/female) Child AbuseChild Abuse suspect of <4 years old,suspect of <4 years old,

especially if nonespecially if non--walking agewalking age

>4 years>4 years – – MVA is the leading causeMVA is the leading cause

Pathological fracture in femur possiblePathological fracture in femur possible – –

NOF, ABC, UBC, EGNOF, ABC, UBC, EG AP/lateral full length femur (visualize AP/lateral full length femur (visualize

hip/knee joint)hip/knee joint)



ClassificationClassification

Greenstick, Buckle vs. CompleteGreenstick, Buckle vs. Complete

(Transverse, Oblique, Spiral, Comminuted,(Transverse, Oblique, Spiral, Comminuted,Segmental)Segmental)

Level : 1/3Level : 1/3’’s,s, subtrochantericsubtrochanteric,,supracondylarsupracondylar



InfantsInfants

Can accept 2Can accept 2--3 cm of short and 303 cm of short and 30

degrees of angulation coronal/sagittaldegrees of angulation coronal/sagittal TX:TX:

Pavlik Harness (stable) (<6 months)Pavlik Harness (stable) (<6 months) Gallows skin tractionGallows skin traction

Hip Spica (unstable)Hip Spica (unstable) immobilize x 2immobilize x 2--3 weeks3 weeks



Age 1 Age 1 -- 66

Hip spica CastHip spica Cast

ContraContra: high energy injury, comminution,: high energy injury, comminution,segmental, spiral, >3 cm shortening onsegmental, spiral, >3 cm shortening on

telescoping test (axial load), head injury, multitelescoping test (axial load), head injury, multi--

traumatrauma external fixator external fixator Proximal fractures hard toProximal fractures hard to TxTx in spica since:in spica since:

fragment tends to flex, adduct, and ERfragment tends to flex, adduct, and ER

2020 varus/valgusvarus/valgus, 20, 20 procurvatun/recurvatumprocurvatun/recurvatum, 1, 1--

2cm short2cm short

Distal 1/3 should be < 20 in any planeDistal 1/3 should be < 20 in any plane



Age 6 Age 6--1010

Hip Spica cast for smaller kids/lowerHip Spica cast for smaller kids/lower

energyenergy External fixator above criteriaExternal fixator above criteria

Flexible intramedullary nails higher energyFlexible intramedullary nails higher energytransverse # patterntransverse # pattern

1515 varus/valgusvarus/valgus, 20, 20

procurvatun/recurvatumprocurvatun/recurvatum, 1cm short, 1cm short



Age >10 Age >10

Flexible intramedullary nailsFlexible intramedullary nails

External fixator External fixator plateplate

No solid IM nailing prior to plate closureNo solid IM nailing prior to plate closure2ndary to High risk of AVN.2ndary to High risk of AVN.



TractionTraction

Very limited indication:Very limited indication: subtrochsubtroch. Fractures. Fractures

(for 90(for 90 – – 9090)) Traction pin in distal femur (medial toTraction pin in distal femur (medial to

lateral insertion proximal to epiphysis)lateral insertion proximal to epiphysis) Convert to hip spica @ 2Convert to hip spica @ 2--3 weeks when3 weeks when

early callus presentearly callus present

Watch for complications of prolonged bedWatch for complications of prolonged bed

rest.rest.

Cl d R d ti d S iClosed Reduction and Spica



Closed Reduction and SpicaClosed Reduction and Spica

castingcasting ProsPros

1.1.

Noninvasive/simpleNoninvasive/simple2.2. No operative related complications (infection,No operative related complications (infection,

NV injury, etc.)NV injury, etc.)

3.3. Rapid union (Rapid union (micromotionmicromotion))4.4. Shortening to offset overgrowthShortening to offset overgrowth

ConsCons

1.1. Sink into varus/short/posterior bowingSink into varus/short/posterior bowing

2.2. inconvenientinconvenient

3.3. knee stiffness in older kidsknee stiffness in older kids



Acceptable Reduction Acceptable Reduction

short <2 cmshort <2 cm

Varus/Valgus 0Varus/Valgus 0--15 valgus15 valgus Antero/Posterior 0 Antero/Posterior 0 – – 15 ant bow15 ant bow

Rotation 10Rotation 10



TechniqueTechnique

GA/Image/Assistant/Spica tableGA/Image/Assistant/Spica table

Mould valgus and straight AP bordersMould valgus and straight AP borders Position Hip 70 flex/30 Abd/15 ER KneePosition Hip 70 flex/30 Abd/15 ER Knee

6060--90 Flex (so heel is clear from bed)90 Flex (so heel is clear from bed) ++++++ Abd Abd = AVN= AVN

Duration 4Duration 4 – – 8 weeks depend on age8 weeks depend on age Weekly FWeekly F--up 2up 2--3 weeks w repeat3 weeks w repeat xrayxray forfor

positionposition



External FixationExternal Fixation Indication: unstable patterns, comminution,Indication: unstable patterns, comminution,

spiral, proximal, open, ++shortening, multispiral, proximal, open, ++shortening, multi--trauma, head injurytrauma, head injury

ProsPros

1.1. Rigid control of deformityRigid control of deformity

2.2. Early wt bearingEarly wt bearing ConCon

1.1. Tethered Quad (stiff knee/hip)Tethered Quad (stiff knee/hip)

2.2. Pin tract infection (5Pin tract infection (5--10 %)10 %)

3.3. RefractureRefracture/pin site fracture/pin site fracture

4.4. Delayed unionDelayed union



TechniqueTechnique

GA/Image/FractureGA/Image/Fracture

table/table/OrthofixOrthofix Set SingleSet Single

lateral bar lateral bar

the initial lateral pin isthe initial lateral pin is

placed farthest from theplaced farthest from the

fracture site (fracture site (‘‘‘‘far far ’’’’ pin) inpin) inthe longer of the twothe longer of the two

fracture fragments. The pinfracture fragments. The pin

can be either a 5can be either a 5--mmmmstandard adult pin or a 4standard adult pin or a 4--

mm pin for smallermm pin for smaller

children.children.



Flexible IM NailsFlexible IM Nails

Indicated for simple transverse/short obliqueIndicated for simple transverse/short obliquefracture pattern, Floating kneefracture pattern, Floating knee

Contra: Unstable patterns comminuted,Contra: Unstable patterns comminuted,segmental, shortenedsegmental, shortened

ProsPros1.1. Early RomEarly Rom

2.2. Early wt bearingEarly wt bearing

ConCon1.1. Rotation/length controlRotation/length control

2.2.

Knee irritationKnee irritation



TechniqueTechnique

GA/Image/radiolucent table/Supine positionGA/Image/radiolucent table/Supine position

Two flexible titanium rods of equal size (eachTwo flexible titanium rods of equal size (each

40% of medullary diameter)40% of medullary diameter) Long C shape with apex @ fracture siteLong C shape with apex @ fracture site

Insertion point Top ofInsertion point Top of condylar condylar flare medial andflare medial and

laterallylaterally proxprox to plateto plate

Incision @ level of superior pole of patellaIncision @ level of superior pole of patella

Insert to level of LT and gently turn duringInsert to level of LT and gently turn duringinsertion to prevent binding on cortexinsertion to prevent binding on cortex

Post opPost op Stable pattern: immediate wt bearingStable pattern: immediate wt bearing

and progress as callus allows, ROM hip andand progress as callus allows, ROM hip andkneeknee



Compression PlatingCompression Plating

indications: polyindications: poly--trauma patients, multipletrauma patients, multiple

extremity fractures (e.g.. Floating knee,extremity fractures (e.g.. Floating knee,Ipsilateral neck/shaft, head injury)Ipsilateral neck/shaft, head injury)

extensile approach neededextensile approach needed



ComplicationsComplications

I.I. MalunionMalunion

Wait 2 years to observe remodelingWait 2 years to observe remodelingpotential and to allow remodelingpotential and to allow remodeling

reaction to settle down (intervention inreaction to settle down (intervention in

this window further stimulatesthis window further stimulates

overgrowth)overgrowth)



PaedsPaeds Distal Femur FracturesDistal Femur Fractures 5% of all physeal injuries.



PaedsPaeds Distal Femur FracturesDistal Femur Fractures

Most commonly SMost commonly S--H I and IIH I and II

injuriesinjuries

Focus on ruling out associatedFocus on ruling out associated

knee/arterial injuryknee/arterial injury esp. withesp. with

anterior displacement of Santerior displacement of S--H IH Iinjuryinjury

Differentiate between physealDifferentiate between physeal

femur # and knee dislocation, Infemur # and knee dislocation, Infemur #femur # patella and femoralpatella and femoral

condylescondyles remain in line withremain in line with

proximal tibiaproximal tibia



PaedsPaeds Distal Femur FracturesDistal Femur Fractures

SS--H II distal fragment displaces in theH II distal fragment displaces in the

direction of the metaphyseal fragmentdirection of the metaphyseal fragment Growth plate under metaphyseal spike isGrowth plate under metaphyseal spike is

usually spared and this affects angularusually spared and this affects angular

deformity: spike medial valgus spikedeformity: spike medial valgus spike

lateral varuslateral varus

T t t



TreatmentTreatment

Type I & IIType I & II closed reduction and LLC in 20closed reduction and LLC in 20 – – 3030

degrees knee flexiondegrees knee flexion

Maneuver: recall periosteum intact on side ofManeuver: recall periosteum intact on side of

displacementdisplacement

1)1) tractiontraction2)2) Increase deformity to remove blocks (for medialIncrease deformity to remove blocks (for medial

displacement varus force)displacement varus force)

3)3) Increase traction and reverse deformity and pushIncrease traction and reverse deformity and push

distal fragment into place (medial to lateral force)distal fragment into place (medial to lateral force)

T t tT t t



TreatmentTreatment

Anterior displacement Anterior displacement Supine, hand 1 behindSupine, hand 1 behindcalf of knee flexed 60 degrees for traction andcalf of knee flexed 60 degrees for traction and

hand 2 forhand 2 for anteriorpressureanteriorpressure over epiphysis to tipover epiphysis to tipit back over distal metaphysisit back over distal metaphysis

Posterior displacementPosterior displacement Prone long tractionProne long traction

with knee in slight flexion, assistant with counterwith knee in slight flexion, assistant with countertraction on proximal thigh, push down ontraction on proximal thigh, push down onepiphyseal fragmentepiphyseal fragment

Cast posterior displacement in full extensionCast posterior displacement in full extension

SS--H II mold cast valgus if met fragment medialH II mold cast valgus if met fragment medialand varus mold if met fragment latand varus mold if met fragment lat

Immobilize 4Immobilize 4 – – 8 weeks non wt bearing8 weeks non wt bearing

T t tT t t



TreatmentTreatment

Acceptable reduction age < 10 yrs 20 Acceptable reduction age < 10 yrs 20

posterior angulationposterior angulation Age >10 yrs. Age >10 yrs. ““minimal AP angulationminimal AP angulation”” < 5< 5

degreesdegrees varus/valgusvarus/valgus

T t tT t t



TreatmentTreatment

Unsuccessful closed reduction/unstableUnsuccessful closed reduction/unstable

(risks: ++ initial displacement/big(risks: ++ initial displacement/bigmetaphyseal fragment)metaphyseal fragment) ORIFORIF

For SFor S--H IIH II percperc fixation incision ipsilateralfixation incision ipsilateral

side to metaphyseal fragmentside to metaphyseal fragment

T t tT t t



TreatmentTreatment

For IrreducibleFor Irreducible Blocks to reduction:Blocks to reduction:

periosteum, capsule, muscle, hematomaperiosteum, capsule, muscle, hematoma Incision opposite side to periostealIncision opposite side to periosteal

hinge/metaphyseal fragment/direction ofhinge/metaphyseal fragment/direction of

displacement, as goal is often to free distaldisplacement, as goal is often to free distal

metaphysis of proximal femoral shaftmetaphysis of proximal femoral shaft

fragment from soft tissuefragment from soft tissue



SS--H I smooth percutaneous wires trans physealH I smooth percutaneous wires trans physeal

proximal distal direction exit @proximal distal direction exit @ condylescondyles and crossand cross

proximal to # siteproximal to # site

T t tTreatment



TreatmentTreatment

SS--H II if ThurstonH II if Thurston--howellhowell

fragment 2fragment 2--3 cm high then 23 cm high then 2

percutaneous cannulatedpercutaneous cannulated

partially threaded 4 .0 or 6.5partially threaded 4 .0 or 6.5

mm screws/washers metmm screws/washers met

met (needs an incision onmet (needs an incision on

ipsilateral side as metaphysealipsilateral side as metaphyseal

spike)spike) Post fixation LLC @ 20 flexionPost fixation LLC @ 20 flexion

x 4x 4 – – 8 weeks non wt bearing8 weeks non wt bearing

TreatmentTreatment



TreatmentTreatment

SS--H III and IV require ORIF for anatomicH III and IV require ORIF for anatomic

reduction of articular surface and growth plate toreduction of articular surface and growth plate to

prevent bony bar formationprevent bony bar formation

Antero medial or lateral incision over fragment Antero medial or lateral incision over fragment

Anatomic reduction checked @ articular surface Anatomic reduction checked @ articular surfacethruthru arthrotomyarthrotomy, @ growth plate, @ fracture, @ growth plate, @ fracture

edgesedges

Cannulated partially threaded 4 .0 or 6.5 mmCannulated partially threaded 4 .0 or 6.5 mm

screws/washers met met/screws/washers met met/epep epep

Post fixation LLC @ 20 flexion x 4Post fixation LLC @ 20 flexion x 4 – – 8 weeks8 weeksnon wt bearingnon wt bearing





Vascular injuryVascular injury highest riskhighest riskwith hyperextensionwith hyperextension

injury/anterior physealinjury/anterior physealdisplacedisplace

Immediate closed reductionImmediate closed reduction

to improve positionto improve position

If circ returns clinicalIf circ returns clinicalobservation +/observation +/-- angioangio to r/outto r/outintimal tear intimal tear

Failed closed reductionFailed closed reductionposterior s shaped approachposterior s shaped approachto poplitealto popliteal fossafossa





Progressive deformity 2 possible causes:Progressive deformity 2 possible causes:

1)1) growth arrestgrowth arrest (S(S--H I&II)H I&II)2)2) bony bar bony bar (S(S--H II&IV)H II&IV)

SS--H II Growth plate under metaphysealH II Growth plate under metaphysealspike is usually spared and this affectsspike is usually spared and this affects

angular deformity: spike medialangular deformity: spike medial valgusvalgus

spike lateralspike lateral varusvarus

SS--H I VarusH I Varus malunionmalunion most commonmost common





Growth arrestGrowth arrest: epiphysiodesis or corrective: epiphysiodesis or corrective

osteotomy @ maturityosteotomy @ maturity Bar Bar : CT or MRI to map out bar : CT or MRI to map out bar

Excision if < 50 % of physis and > 2yrsExcision if < 50 % of physis and > 2yrsgrowth remaininggrowth remaining

Direct approach for peripheralDirect approach for peripheral

bar/metaphyseal window for central bar bar/metaphyseal window for central bar





Growth disturbanceGrowth disturbance

Usually if < 2yrs growth remainingUsually if < 2yrs growth remaining LLdLLd notnotsignificantsignificant

Bone age andBone age and scanogramscanogram Q 6 months x 3Q 6 months x 3and plot onand plot on MoselyMosely graph to predict LLDgraph to predict LLD

@ maturity@ maturity

< 2.5 cm NO< 2.5 cm NO TxTx, > 2.5 cm epiphysiodesis,, > 2.5 cm epiphysiodesis,

> 5 cm lengthening> 5 cm lengthening



Thank youThank you

pediatric femur fracture

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