arvin noscal pediatric femur
Transcript of 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)
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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
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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
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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
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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)
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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
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12 yo 200 lb female unstable fx
treated with flexible nails healed
with 30 degree procurvatum malunion
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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
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Timmermann and Rab
JOT 1993
Most children with fractures ofthe femur have a satisfactoryoutcome with any reasonable form
of treatment.
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