Femur Fxby Tahir

8/14/2019 Femur Fxby Tahir

1/77

Pediatric Femoral ShaftPediatric Femoral Shaft

FracturesFractures

Dr. Tahir MahmoodDr. Tahir MahmoodLahore General HospitalLahore General Hospital

LahoreLahore


2/77

Pediatric Femur FracturesPediatric Femur Fractures

1.6 % of all children Fractures1.6 % of all children Fractures

28/100,000 child per year 28/100,000 child per year

3:1 Male / Female ratio3:1 Male / Female ratioChildren >3 yrs- highest incidenceChildren >3 yrs- highest incidence

Seasonal- highest summer Seasonal- highest summer


3/77

Anatomy and GrowthAnatomy and Growth

Proximal femoralProximal femoral physis- 30% of physis- 30% of longitudinal growthlongitudinal growth

Distal femoral physis-Distal femoral physis-70% of longitudinal70% of longitudinalgrowthgrowth

Rapid increase inRapid increase incortical thicknesscortical thickness


4/77

Pediatric Femur Fractures-Pediatric Femur Fractures-Mechanism of InjuryMechanism of Injury

Rule out child abuseRule out child abuse

Falls- young children/toddlersFalls- young children/toddlers

Struck by vehicle- juvenileStruck by vehicle- juvenile

Recreational sports/activities- adolescentRecreational sports/activities- adolescent

Motor vehicle crashes- all age groupsMotor vehicle crashes- all age groups


5/77

Mechanism of InjuryMechanism of Injury

Low EnergyLow Energy

High EnergyHigh Energy

* predicts predicts behavior/treatment of behavior/treatment of the fracturethe fracture


6/77

Pediatric Femur Fractures-Pediatric Femur Fractures-Associated InjuriesAssociated Injuries

Struck by car- triad of femur fracture, torsoStruck by car- triad of femur fracture, torsoinjuries, head injuryinjuries, head injury

Potential damage to physis of femur andPotential damage to physis of femur and proximal tibia proximal tibia

Head Injury spasticity can make traction andHead Injury spasticity can make traction andcast treatment difficultcast treatment difficult

Abdominal injury spica cast can constrictAbdominal injury spica cast can constrictabdomen and limit ability to examineabdomen and limit ability to examine


7/77

Spasticity Leading to ExtremeSpasticity Leading to ExtremeAngulation and ShorteningAngulation and Shortening


8/77

Physical ExamPhysical Exam

Complete exam: head, chest, abdomen, andComplete exam: head, chest, abdomen, andother skeletal segmentsother skeletal segments

Document distal neurological and vascular Document distal neurological and vascular functionfunction

Palpate all bonesPalpate all bones

First Aid principles - Splint or traction,First Aid principles - Splint or traction,especially prior to transfer to another especially prior to transfer to another institutioninstitution


9/77

Radiographic EvaluationRadiographic Evaluation

AP PelvisAP Pelvis

AP/Lat femur AP/Lat femur

Visualize hip & kneeVisualize hip & knee joints joints


10/77

ClassificationClassification

Fracture patternFracture patterntransverse, spiral, oblique, comminuted, greenstick transverse, spiral, oblique, comminuted, greenstick

Amount of shorteningAmount of shorteningAngular deformityAngular deformityOpen / closedOpen / closed


11/77

7 Principles7 PrinciplesDameron & ThompsonDameron & Thompson

1. Simplest treatment best1. Simplest treatment best

2. Initial treatment permanent when possible2. Initial treatment permanent when possible

3. Perfect anatomic reduction not essential for 3. Perfect anatomic reduction not essential for perfect function perfect function

4. More potential growth= more remodeling4. More potential growth= more remodeling

capabilitycapability


12/77

7 Principles7 PrinciplesDameron & Thompson JBJS 1959Dameron & Thompson JBJS 19595. Restoration of alignment more important5. Restoration of alignment more important

than fragment positionthan fragment position

6. Over treatment usually worse than under 6. Over treatment usually worse than under

treatmenttreatment

7. Immobilize/splint injured limb before7. Immobilize/splint injured limb beforedefinitive treatmentdefinitive treatment


13/77

Treatment Goals - RestoreTreatment Goals - Restore

LengthLength

AlignmentAlignmentRotationRotation


14/77

Treatment Goals - AvoidTreatment Goals - Avoid

Osteonecrosis - disruption of blood supplyOsteonecrosis - disruption of blood supplyto femoral headto femoral headPhyseal injury- preserve future growthPhyseal injury- preserve future growth

potential (proximal and distal femoral potential (proximal and distal femoral physis, trochanteric apophysis) physis, trochanteric apophysis)


15/77

Complication of fracture femurComplication of fracture femur

Leg lengthLeg lengthdiscrepancydiscrepancy

shorteningshortening

over growthover growthAngular deformityAngular deformityRotational deformityRotational deformity

Delayed unionDelayed union


16/77

Complication of fracture femurComplication of fracture femur

Non union Non union

Muscle weaknessMuscle weaknessInfectionInfection

Neurovascular injury Neurovascular injury

Compartment syndromeCompartment syndrome


17/77

Decision MakingDecision Making

AgeAge

Mechanism of injuryMechanism of injury

Fracture pattern &Fracture pattern &locationlocationAssociated InjuriesAssociated Injuries

Surgeon preferenceSurgeon preference

Available resourcesAvailable resources


18/77

Treatment optionsTreatment options

Age Treatment.Age Treatment.

Birth to 24 mo padding & soft splintBirth to 24 mo padding & soft splint

Pavlik harness (newborn to 6 mo)Pavlik harness (newborn to 6 mo)

Immediate spica castImmediate spica castTraction ~spica castTraction ~spica cast

2 yrs to 5 yrs Immediate spica cast2 yrs to 5 yrs Immediate spica cast

Traction ~ spica castTraction ~ spica cast

External fixation (rare)External fixation (rare)TEN (rare)TEN (rare)


19/77

Treatment optionsTreatment options

6 yrs to 11 yrs Traction ~ spica cast6 yrs to 11 yrs Traction ~ spica cast

Compression plateCompression plate

TENTEN

External fixationExternal fixation

12 yrs to maturity TEN12 yrs to maturity TEN

Compression plateCompression plate

Locked IMNLocked IMNExternal fixationExternal fixation


20/77

Acceptable angulationsAcceptable angulations

Age Varus/ Anterior/ ShorteningAge Varus/ Anterior/ Shortening

Valgus Posterior (mm)Valgus Posterior (mm)

(degrees) (degrees)(degrees) (degrees)Birth to 2yrs 30 30 15Birth to 2yrs 30 30 15

2-5 yrs 15 20 202-5 yrs 15 20 20

6-10 yrs 10 15 156-10 yrs 10 15 1511yrs to maturity 5 10 1011yrs to maturity 5 10 10


21/77

Traction TechniquesTraction Techniques

Skin or skeletalSkin or skeletal

Longitudinal in line traction for comfort prior Longitudinal in line traction for comfort prior to definitive treatmentto definitive treatment

Longitudinal in line traction for comfort prior Longitudinal in line traction for comfort prior to definitive treatmentto definitive treatment


22/77

Traction TechniquesTraction Techniques

Vertical over headVertical over headtraction hip flexed 90traction hip flexed 90

degree (Bryant 1973)degree (Bryant 1973)Split RussellsSplit Russellstraction (90-90) if traction (90-90) if awaiting earlyawaiting earlyhealing prior tohealing prior tocastingcasting


23/77

Skeletal Traction TechniquesSkeletal Traction Techniques

Avoid physis if placeAvoid physis if placeskeletal traction pinsskeletal traction pins

Place pin perpendicular Place pin perpendicular

to shaft to avoidto shaft to avoidvarus/valgus angulationvarus/valgus angulation


24/77

Subtrochanteric fracture treated with tractionSubtrochanteric fracture treated with tractionfollowed by one legged ambulatory spica castfollowed by one legged ambulatory spica cast


25/77

Immediate Spica Cast-Immediate Spica Cast-ideal patientideal patient

Less than 5 years oldLess than 5 years old

Less than 50 lbsLess than 50 lbs

Initial shortening not excessiveInitial shortening not excessiveIsolated injuryIsolated injury

Note -Spica casts used for decades and can Note -Spica casts used for decades and canwork for almost any pediatric femur fracturework for almost any pediatric femur fracture


26/77

Spica Cast TechniqueSpica Cast Technique

Appropriate paddingAppropriate paddingCast liners may decreaseCast liners may decreaseskin problemsskin problemsTraction to get 0-15 mmTraction to get 0-15 mmshorteningshorteningMold laterally to preventMold laterally to preventvarusvarusCan wedge forCan wedge for

unacceptable angulation atunacceptable angulation at1-2 week 1-2 week checkupscheckups


27/77


28/77


29/77

Spica CastSpica Cast

Fiberglass lighter, easier Fiberglass lighter, easier to x-ray throughto x-ray through

Often strong enough toOften strong enough to

obviate need for obviate need for connecting bar connecting bar


30/77

Sitting spica 3 part, 90-90Sitting spica 3 part, 90-90

This technique, recommended intextbooks and articles, may increaserisk of developing compartmentsyndrome


31/77

Current technique Above knee cast first.Current technique Above knee cast first.Hip and knee- 40-45 flexion, foot out.Hip and knee- 40-45 flexion, foot out.Can include opposite thigh if desired.Can include opposite thigh if desired.


32/77

Immediate Spica CastImmediate Spica Cast

X-ray weekly for 3X-ray weekly for 3weeksweeksTime in spica = age inTime in spica = age in

years + 3 weeks up toyears + 3 weeks up tomaximum 8 weeksmaximum 8 weeksWedge cast for Wedge cast for malalignmentmalalignment

Rotational alignmentRotational alignmentimportant at initial castimportant at initial castapplicationapplication


33/77

ComplicationsComplications

Closed treatment of Closed treatment of childrens femur fractureschildrens femur fracturesresulted in the mostresulted in the most

frequent and expensivefrequent and expensivecomplications, includingcomplications, includingfoot drop, skin loss,foot drop, skin loss,compartment syndrome,compartment syndrome,

and malrotation /and malrotation /shortening.shortening.

C d li i lC d li i l


34/77

Compartment syndrome complicating earlyCompartment syndrome complicating earlyspica cast treatment of isolated femoral shaftspica cast treatment of isolated femoral shaft

fractures in childrenfractures in children- JBJS Nov 03- JBJS Nov 03


35/77


36/77

Mold into slightvalgus desired on

initial radiographafter casting


37/77

Femoral Remodeling afterFemoral Remodeling afterFractureFracture

Will not correct significantWill not correct significantrotational malunionrotational malunion(Davids, Clin Orthop)(Davids, Clin Orthop)Overgrowth 1-1.5 cm mayOvergrowth 1-1.5 cm mayoccur, especially inoccur, especially inyounger children treatedyounger children treatednonoperativelynonoperativelyAngular deformity willAngular deformity willremodel significantly inremodel significantly inchildren 10years oldyears old


38/77

Trend Toward MoreTrend Toward More

Invasive TreatmentInvasive TreatmentMore high energy fracturesMore high energy fractures

Improved operative techniquesImproved operative techniquesFailed nonoperative treatmentFailed nonoperative treatment

Simplifies patient careSimplifies patient carePsychological, social and financialPsychological, social and financial

reasonsreasons


39/77

Ambulatory Treatment OptionsAmbulatory Treatment Options

Plate & screw fixationPlate & screw fixation

External fixationExternal fixation

Flexible nailingFlexible nailing

Rigid nailingRigid nailing

Bridge plating / MIPPO/ locked platesBridge plating / MIPPO/ locked plates


40/77

Flexible NailingFlexible Nailing

AdvantagesAdvantagesAllows earlyAllows earlymobilization without castmobilization without cast

Cosmetic scarsCosmetic scarsAvoids physis and bloodAvoids physis and bloodsupply to femoral headsupply to femoral head


41/77

12 yo male in RTA accidentClosed proximal third, oblique fractureBack at school 2 weeks

Walking at 8 weeks


42/77

Flexible NailingFlexible Nailing

DisadvantagesDisadvantages

Ends may irritate softEnds may irritate softtissuestissues

May not be amenable toMay not be amenable tosome fracture patternssome fracture patterns(very proximal or distal,(very proximal or distal,comminution)comminution)


43/77

Flexible NailsFlexible Nails

Titanium elasticTitanium elasticintramedullary nailingintramedullary nailing(TEIN)(TEIN)

popular choice to popular choice tostabilize pediatric femur stabilize pediatric femur fractures in children > 5fractures in children > 5yrsyrs

little published onlittle published oncomplicationscomplicationsJBJS Br 2006JBJS Br 2006

Healed 5 cm short


44/77

Most complications minorMost complications minor

Nail Irritation (16%) -Nail Irritation (16%) -dont bend endsdont bend ends

- all resolved post- all resolved post


45/77

Cut pins above physis with screwCut pins above physis with screwcuttercutter


46/77

13yo male, 94 lbs -nails too short, back out, get13yo male, 94 lbs -nails too short, back out, getinfected, have to be removed, varus malunion withinfected, have to be removed, varus malunion with

shorteningshortening


47/77

12 yr old female, 130 lbs12 yr old female, 130 lbsVarus, procurvatum malunionVarus, procurvatum malunion

TEIN i ld d ll t ti f t ltTEIN yielded excellent or satisfactory results


48/77

TEIN yielded excellent or satisfactory resultsTEIN yielded excellent or satisfactory resultsin 90% of casesin 90% of cases


49/77

Outcome was better in a higher percentage of Outcome was better in a higher percentage of central-third fracturescentral-third fractures

Be aware of prox 1/3- mid 1/3Be aware of prox 1/3- mid 1/3


50/77

Be aware of prox 1/3- mid 1/3Be aware of prox 1/3 mid 1/3 junction fracture with medial junction fracture with medial

butterflybutterfly

Recommendations :Recommendations :


51/77

Recommendations :Recommendations :> 11 years, > 108 lbs> 11 years, > 108 lbs

consider other treatment options consider other treatment options


52/77

ORIF with Plates/ScrewsORIF with Plates/Screws

AdvantagesAdvantagesAnatomical reductionAnatomical reduction

Rigid fixationRigid fixation

Technique familiar to most surgeonsTechnique familiar to most surgeons

Allows early motionAllows early motion

Simplified nursing careSimplified nursing care

Favorable results reported in children withFavorable results reported in children withassociated head injuriesassociated head injuries


53/77

ORIF with Plates/ScrewsORIF with Plates/Screws

DisadvantagesDisadvantagesLarge scar Large scar

Implant failureImplant failure

Possible refracture after plate removedPossible refracture after plate removed

Second anaesthesia for implant removalSecond anaesthesia for implant removal

Higher infection rateHigher infection rate


54/77

ORIF Plate FixationORIF Plate Fixation


55/77

Percutaneous BridgePercutaneous BridgePlatingPlating


56/77

f


57/77

Previous fracture with endostealPrevious fracture with endostealcallus- plate good optioncallus- plate good option


58/77

External FixationExternal Fixation

AdvantagesAdvantagescan be applied rapidly,can be applied rapidly,

allows soft tissue injuryallows soft tissue injury

management ,management ,early mobilization,early mobilization,

Good option in openGood option in openfractures & poly traumafractures & poly trauma

patients patients


59/77

External FixationExternal Fixation

DisadvantagesDisadvantages pin site sepsis, pin site sepsis,

pin site scarring, pin site scarring,

refracture,refracture,malunionmalunion


60/77

11 yrs male RSA

Pelvic fracture, ruptured bladder

External fixation


61/77

Ex Fix Fracture at Prox PinEx Fix Fracture at Prox Pin

Keep pin diameter


62/77

Ex Fix RefractureEx Fix Refracture

6 months post injury


63/77

External Fixator TipsExternal Fixator Tips

Appropriate size half pin diameter Appropriate size half pin diameter

Proper pin placement relative to fracture for Proper pin placement relative to fracture for biomechanical rigidity biomechanical rigidity

Do not remove ex fix until see bridgingDo not remove ex fix until see bridgingcorticescortices


64/77

Medium Multi-Pin Clamp

Clamp is parallelto boneSchanzscrew is

perpendicular to bone

2cm

2cm

2cm

2cm

O F F tO F F t


65/77

Open Femur FractureOpen Femur FracturePrinciplesPrinciples

IV antibiotics, tetanusIV antibiotics, tetanus prophylaxis prophylaxisemergent irrigation &emergent irrigation &debridementdebridementskeletal stabilizationskeletal stabilizationExternal fixation bestExternal fixation bestoption with severe softoption with severe soft

tissue injurytissue injurysoft tissue coveragesoft tissue coverage


66/77

Open FracturesOpen Fractures

Can use temporary shunting torestore distal perfusion duringdebridement


67/77

Trochanteric Nail TechniqueTrochanteric Nail Technique

Stay out of piriformis fossaStay out of piriformis fossa

Some use large incision/open approachSome use large incision/open approach

Over ream/small nail - starting hole and canalOver ream/small nail - starting hole and canalnonlinear nonlinear

Large diameter nail ? benefit (no reportedLarge diameter nail ? benefit (no reportednail fractures, nonunion rare)nail fractures, nonunion rare)


68/77

Piriformis Fossa Entry SitePiriformis Fossa Entry Site

Raney E. JPO, 1993.

Thometz J, JBJS 1995.

Astion D, JBJS 1995

A t Bl d S l P i lAnatom Blood S ppl Pro imal


69/77

Anatomy- Blood Supply ProximalAnatomy- Blood Supply ProximalFemoral EpiphysisFemoral Epiphysis

Predominantly ascendingPredominantly ascendingcervical branch (B) of cervical branch (B) of medial circumflex femoralmedial circumflex femoralarteryarteryPhysis (D) - a barrier toPhysis (D) - a barrier tointraosseous blood supplyintraosseous blood supply

from femoral neck from femoral neck


70/77

Ganz, et al


71/77

12 year old male, 6 mos12 year old male, 6 mos


72/77

Small diameter solid nail, unreamedSmall diameter solid nail, unreamed

Trochanteric entryTrochanteric entry


73/77

Trochanteric entryTrochanteric entryProximal and distal interlockingProximal and distal interlocking


74/77

Leave some bone medial to nailLeave some bone medial to nail


75/77

Nail removalNail removal

Some controversySome controversyCommonlyCommonlyrecommendedrecommended

Survey studies removeSurvey studies removeIM devices in childrenIM devices in childrenOutpatient procedureOutpatient procedureGrasping pliersGrasping pliers

No sports for 4 weeks No sports for 4 weeksReturn for x-rayReturn for x-ray4 weeks post removal4 weeks post removal


76/77

SummarySummary

< 5 years early spica cast, changed technique< 5 years early spica cast, changed technique5-11 years, < 100 lbs TEN5-11 years, < 100 lbs TEN> 11, > 100 lbs trochanteric entry nail or > 11, > 100 lbs trochanteric entry nail or

bridge plating bridge platingVery distal or very proximal fracture, closedVery distal or very proximal fracture, closedIM canal, or severe axial instability bridgeIM canal, or severe axial instability bridge

plating platingSevere soft tissue injury- external fixationSevere soft tissue injury- external fixation


77/77

Documents

Femur Fxby Tahir