pediatric femur fracture
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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
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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))
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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)
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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
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Treatment (Based onTreatment (Based on DelbetDelbet
Classification)Classification)
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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
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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
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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
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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
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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
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A 6-year-old boy was struck by an automobile and sustained
a displaced type III fracture.
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Complications & ManagementComplications & Management
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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
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Complications & ManagementComplications & Management
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
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Complications & ManagementComplications & Management
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
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Complications & ManagementComplications & Management
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
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Complications & ManagementComplications & Management
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
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Complications & ManagementComplications & Management
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
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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
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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)
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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)
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PaedsPaeds Distal Femur FracturesDistal Femur Fractures 5% of all physeal injuries.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
ComplicationsComplications
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ComplicationsComplications
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
ComplicationsComplications
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ComplicationsComplications
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
ComplicationsComplications
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ComplicationsComplications
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
ComplicationsComplications
8/19/2019 Pediatric Femur Fracture
http://slidepdf.com/reader/full/pediatric-femur-fracture 51/52
ComplicationsComplications
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
8/19/2019 Pediatric Femur Fracture
http://slidepdf.com/reader/full/pediatric-femur-fracture 52/52
Thank youThank you
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