arvin noscal pediatric femur

8/7/2019 arvin noscal pediatric femur

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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


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Pediatric Femur Fractures

1.6 % all children's Fxs 28/100,000 child years (Holland)

3:1 Male / Female ratio

Children >3 y.o.- highest incidence Seasonal- highest summer


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Treatment Goals - Restore

Length

Alignment Rotation


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Treatment Goals - Avoid

Osteonecrosis - disruption of blood supply

to femoral head

Physeal injury- preserve future growth

potential (proximal and distal femoral

physes, trochanteric apophysis)


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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


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Anatomy- Blood Supply

Proximal Femoral Epiphysis Predominantly

ascending cervical

branch (B) of medialcircumflex femoral

artery

Physis (D) - a barrier

to intraosseous blood

supply from femoral

neck

Chung S. JBJS 58A, 1976


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Pediatric Femur Fractures-

Mechanism of Injury Rule out NAT in children


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Mechanism of Injury Low Energy

High Energy

*predictsbehavior/treatment of the

fracture (Blount-1973,

Pollack-1994)


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Pediatric Femur Fractures-

Associated Injuries Struck by car- triad of femur fracture, torso

injuries, head injury

Potential damage to physes of femur andproximal tibia

Head Injury spasticity can make traction

and cast treatment difficult Abdominal injury spica cast can constrict

abdomen and limit ability to examine


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Spasticity Leading to Extreme

Angulation and Shortening


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Physical Exam Complete exam: head, chest, abdomen, and

other skeletal segments

Document distal neurologic and vascularfunction

Palpate all bones

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


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Radiographic Evaluation AP Pelvis

AP/Lat femur

Visualize hip & knee joints


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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


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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


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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


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Decision Making Age

Mechanism of injury

Fracture pattern & location

Associated Injuries

Surgeon preference


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Traction

Techniques

Skin or skeletal

Avoid physes if place skeletal traction pins

Place pin perpendicular to shaft to avoidvarus/valgus angulation

Longitudinal in line traction for comfort

prior to definitive treatment Split Russells traction (90-90) if awaiting

early healing prior to casting


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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


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Spica CastT

echnique 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)


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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


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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


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Compartment Syndrome Complicating

Early Spica Cast Treatment of

Isolated Femoral Shaft Fractures in Children- JBJS Nov 03


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Early Sitting Spica

3 Part, Below Knee Cast FirstMethod, 90-90 Position

This technique, recommended in

textbooks and articles, may increase

risk of developing compartment

syndrome, and is not recommended


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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


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AAOS Managing Orthopaedic

Malpractice Risk 2000 Closed treatment of

childrens femur fractures

resulted in the mostfrequent and expensive

complications, including

foot drop, skin loss,

compartment syndrome,and malrotation /

shortening.


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Mold into slight valgus

desired on initial

radiograph after casting


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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 10 years old


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Surgical Options Plate & screw fixation

External fixation

Flexible nailing

Rigid nailing


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ORIF with Plates/Screws Advantages rigid, technique familiar to

most surgeons, allows early motion,

favorable results reported in children withassociated head injuries

Disadvantages- large scar, possible

refracture after plate removed, higherinfection rate in some earlier series


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ORIF Plate Fixation


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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


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11 yo male MVC

Pelvic fracture, ruptured bladder

External fixation


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Ex Fix Fracture at Prox Pin

Keep pin diameter


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Ex Fix Refracture

6 months post injury


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External FixatorT

ips 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)


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Open Femur Fracture

Principles IV antibiotics, tetanus

prophylaxis

emergent irrigation &debridement

skeletal stabilization

External fixation best

option with severe softtissue injury

soft tissue coverage


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Open Fractures

Can use temporary shunting to

restore distal perfusion during

debridement


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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 (veryproximal or distal, comminution)


39/84


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12 yo male in ATV accident

Closed proximal third, oblique

Back at school 2 weeks

Walking at 8 weeks


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Titanium Elastic Nailing - Results

Flynn et al. JPO Jan 2001

57/58 excellent or satisfactory

No rotational malunions 6/58 1-2 cm LLD


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Titanium Elastic Nailing -

Complications

Flynn 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


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Titanium Elastic IntramedullaryNailing of Pediatric Femur Fractures:

Predictors of Complications and Poor

OutcomesMulticenter Study

Launay, Flynn, Moroz, Frick, Kocher,Newton, Sponseller

2004 POSNA, OTA meetings

JBJS Br 2006


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Materials and Methods Surgeons at 6 pediatric

trauma centers

Consecutive series offemur fractures treatedwith 2 retrogradetitanium nails

Analysis ofcomplications


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Cohort 234 femoral shaft

fractures in 229

patients 114 complications in

87 cases


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Results Excellent in 148 cases

(64%)

Satisfactory in 59cases (26%)

Poor in 23 cases

(10%)


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Most Complications Minor

Nail Irritation (16%)Nail Irritation (16%) --dont bend endsdont bend ends-- all resolved post removalall resolved post removal


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Cut Pins above Physis with

Screw Cutter


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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


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TEIN Yielded Excellent or Satisfactory

Results in 90% of Cases


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Outcome was better in a higher percentage of

central-third fractures (p=0.55)


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Children with Poor Results were

Heavier, Cut-off Weight 108 lbs


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Complications more Likely

in Children Older than 11 Years


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Recommendations :

> 11 years, > 108 lbs

Consider otherTreatment Options


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Cincinnati Childrens Hospital Series

Mehlman, et al.

Presented OTA 2004

Similar excellent results in most patients

Poor results / complications more likely inpatients who were older and who weighed

more than 99 lbs


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Flexible Nails

Multiple studies from

multiple institutions

now report excellentoutcomes with few

complications

If fracture pattern

allows this is thepreferred method of

fixation for many


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Rigid Nailing

Advantages rigid fixation, control rotation

with interlocking screws

Disadvantages -Risks injury to proximal

femoral epiphysis (rare but possible

devastating complication of osteonecrosis),may interfere with trochanteric growth


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Why Not Use Rigid Nail?

Concern about AVN / osteonecrosis

of the femoral head if use piriformisfossa entry portal


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Anatomy

Epiphyseal

blood supply

Traverses the

piriformis

fossa

Vulnerable

near greater

trochanter

Chung S. JBJS 58A, 1976.


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Piriformis Fossa Entry Site

Raney E. JPO, 1993.

Thometz J, JBJS 1995.

Astion D, JBJS 1995


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THE DATA

English Literature Estimated AVN Prevalence = 1-2%

1996 POSNA membership survey

15 cases identified

All following Rigid Reamed Nail None following flexible nailing

1 published case after trochanteric entry

6 Published Case Reports

13 Published Case Series


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Case Series Summary

AUTHOR PUBLICATION # PTS AVG AGE IMPLANT TECHNIQUE MAL/DELAY AVN LLD>2cm PROX F/U

Kirby JPO 1981 13 14 (10) K R, PF 0 0 0 1 16

Herndon JPO 1990 16 13 + 9 (11) K, AO R, PF 0 0 0 0 16

Reeves JPO 1990 33 14 + 11 (11) K, AO R, PF 0 0 0 0 --

Ziv JOT 1984 8 8 + 4 (6) K R, PF 0 0 0 3 90Jaglan AAOS 1992 44 12 (5) -- -- 1 -- 0 0 21

Maruenda Int Orthop 1993 29 11 +8 (7) K R, PF 0 0 0 1 80

Timmerman JOT 1993 20 13 + 10 (10) K, AO, GF R, PF 0 0 0 0 27

Beaty * JPO 1994 31 12 + 3 (10) RT R, L, PF 0 1 2 1 23

Galpin JPO 1994 22 12 + 9 (11) GK, AO R, L, PF 0 0 1 5 33

Garside POSNA 1994 17 9 + 6 (7) RT R, L, PF 0 0 0 4 27

Buford * CORR 1998 54 12 (6) ? R, L, PF 0 2 0 -- 20

Stans * JPO 1999 13 13 + 6 (11) R, L, GT 0 1 0 0 19

Townsend CORR 2000 34 12 + 1 (10) RT R, L, GT 0 0 0 0 24

TOTAL 334 12 1 4 3 15


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Thometz et al., JPO 1995

CASE REPORT 12 y.o. boy,s/p MVA

Pre-existing AsxAcetabular Dysplasia +

Coxa Valga Curved Kntscher Nail

PIRIFORMIS FOSSA

Pain @ 9 mo. post-op

ROH

AVN @ 9 mo.

Osteotomies @ 15 mo.


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IM Nailing vs. Non-op Treatment

Kirby et al., JPO 1981

Traction / Spica vs. Closed IM Nailing

Herndon et al., JPO 1989

Traction / Spica vs. Closed IM Nailing

# Pts. Avg Age Union Hosp stay Results

Spica 24 13 +3 11.5 wk 28 d Malunion (7), >2.5 cm short (3)

Nail 21 13 +9 10 wk 17 d

# P ts . A vg A ge Hosp s tay Results

Spica 13 12 +8 30.5 d M alunion (4), > 2.5 cm short (2)

Nail 12 14 +0 20.6 d Trochanteric A rres t (1)


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IM Nailing vs. Non-op Treatment

Reeves et al., JPO 1990

Traction / Spica vs. Internal Fixation

30 Kuntscher Rods

19 Plates

# Pts. Avg Age Hosp stay Cost Results

Spica 41 12 +4 26 d 11,800 Delayed union (4), Malunion (5),

Growth disturbance (4), Psychotic

Episodes (2)

Internal Fixation 49 14 +11 9 d 8,100 Transient Peroneal Palsy (1)

T d i P di i F


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Trends in Pediatric Femur

Fracture Management Much less frequent traction- casting

Immediate spica if


67/84

Trochanteric Nailing

Vanderbilt Series >175 patients, 2 year f/u

>age 8 years

All healed

No length equalization procedures or lifts

No AVN, no coxa valga

Nail removal at 6 -12 mos if growing or if

symptomatic in older adolescentNot published


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Lateral Trochanteric Nailing

St. Louis Series 15 patients, 1 year follow-up

Avg age 12.5 (8-17)

All healed

No change articulotrochanteric distance

Avoid tip of trochanter, all placed with

lateral trochanteric entry site


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St. Louis Pediatric Femoral Nail

8,9 and 10 mm

Over 8 years, >200 cases

All patients > 8 yrs old

>150 fractures, also osteotomies

135 followed > 1 year, 75 > 2 years

No AVN

No significant coxa vara


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12 Year Old Male, 6 Mos.


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Trochanteric Nail Technique

Stay out of piriformis fossa area

Some use large incision/open approach

Oveream/small nail - starting hole and canalnonlinear

Large diameter nail ? benefit (no reported

nail fractures, nonunion rare) Some designs now for small diameter, solid

unreamed nail


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Small Diameter Solid Nail,

Unreamed


73/84

Trochanteric Entry

Proximal and Distal Interlocking


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Leave some Bone Medial to Nail

in Trochanter

T d i P di t i F


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Trends in Pediatric Femur

Fracture Management

Trochanteric entry rigid

nailing- new designs, large

experience in some centers

Limited/minimal incisionplating techniques- bridge

plate concept- popular in few

trauma centers, useful for

some fracture

patterns/locations External fixation for severe

soft tissue injuries in open

fractures


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Percutaneous Bridge

Plating

Courtesy of E.M. Kanlic, MD, PhD


77/84

Bridge Plating

Limited incisions anddissection

Usually 4.5 mm plate andscrews

Long plate, few screws, donot open fracture site

An internal fixator Excellent results published by

Kanlic (Clinical Orthop) andSink (J Pediatr Orthop)


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Submuscular Plating

Small incisions either end

Extraperiosteal, slide plate

At least 2 screws in each main fragment

Clustered screws vs. near-near, far-far

Reduce fracture and maintain before plating

(bumps or temporary ex-fix)


79/84

Metal Removal

Some controversy

Commonly recommended

Survey studies removeIM devices in children

Some centers now do not

electively remove

asymptomatic implants

Excellent review by

Peterson, J Pediatr Orthop

2005


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Complications of Femoral Shaft

Fractures Limb length discrepancy shortening most

frequent

Malunion (angular, rotational) Nonunion rare

Osteonecrosis femoral head (rigid nailing)

Refracture (ex fix, plate removal)

Osteomyelitis (after operative treatment)

Traction pin injury to physes possible


81/84

12 yo 200 lb female unstable fx

treated with flexible nails healed

with 30 degree procurvatum malunion


82/84

13 yo male hit by car

Initially 2 retrogradeTEN

1 became prominent

Healed 5 cm short

Lengthened over

nail

Healed with equal LL

Courtesy of

S.H.Sims, MD


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Trend Toward More

Invasive TreatmentMore high energy fractures

Improved operative techniquesFailed nonoperative treatment

Simplifies patient carePsychological, social and financialreasons


84/84

Timmermann and Rab

JOT 1993

Most children with fractures ofthe femur have a satisfactoryoutcome with any reasonable form

of treatment.

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