4. Treatment Goals - Avoid
• Osteonecrosis - disruption of blood supply
to femoral head
• Physeal injury- preserve future growth
potential (proximal and distal femoral
physes, trochanteric apophysis)
5. 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
6. Anatomy- Blood Supply
Proximal Femoral Epiphysis
• Predominantly
ascending cervical
branch (B) of medial
circumflex femoral
artery
• Physis (D) - a barrier
to intraosseous blood
supply from femoral
neck
Chung S. JBJS 58A, 1976
7. Pediatric Femur Fractures-
Mechanism of Injury
• Rule out NAT in children <1year old
• Falls- young children/toddlers
• Struck by car- juvenile
• Recreational sports/activities- adolescent
• Motor vehicle crashes- all age groups
8. Mechanism of Injury
• Low Energy
• High Energy
*predicts
behavior/treatment of the
fracture (Blount-1973,
Pollack-1994)
9. Pediatric Femur Fractures-
Associated Injuries
• Struck by car- triad of femur fracture, torso
injuries, head injury
• Potential damage to physes of femur and
proximal tibia
• Head Injury – spasticity can make traction
and cast treatment difficult
• Abdominal injury – spica cast can constrict
abdomen and limit ability to examine
10. Physical Exam
• Complete exam: head, chest, abdomen, and
other skeletal segments
• Document distal neurologic and vascular
function
• Palpate all bones
• First Aid principles - Splint or traction
12. 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
13. 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
14. 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
15. Decision Making
• Age
• Mechanism of injury
• Fracture pattern & location
• Associated Injuries
• Surgeon preference
16. Traction Techniques
• Skin or skeletal
• Avoid physes if place skeletal traction pins
• Place pin perpendicular to shaft to avoid
varus/valgus angulation
• Longitudinal in line traction for comfort
prior to definitive treatment
• Split Russells traction (90-90) if awaiting
early healing prior to casting
17. 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
18. Spica Cast Technique
• 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 week check
(>10-20° varus/valgus, >15-30°
procurvatum/recurvatum – age dependent)
19. 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
20. 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
23. Femoral Remodeling
after Fracture
• Will not correct significant rotational
malunion
• Overgrowth 1-1.5 cm may occur, especially
in younger children treated nonoperatively
• Angular deformity will remodel
significantly in children <5 years old, less
reliably in 5-10 year old, and is unlikely to
be substantial in children >10 years old
25. ORIF with Plates/Screws
• Advantages – rigid, technique familiar to
most surgeons, allows early motion,
favorable results reported in children with
associated head injuries
• Disadvantages- large scar, possible
refracture after plate removed, higher
infection rate in some earlier series
27. 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
28. 11 yo male MVC
Pelvic fracture, ruptured bladder
External fixation
29. External Fixator Tips
• 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)
30. Open Femur Fracture
Principles
• IV antibiotics, tetanus
prophylaxis
• emergent irrigation &
debridement
• skeletal stabilization
• External fixation best
option with severe soft
tissue injury
• soft tissue coverage
32. 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 (very
proximal or distal, comminution)
33.
34. 12 yo male in ATV accident
Closed proximal third, oblique
Back at school 2 weeks
Walking at 8 weeks
35. Titanium Elastic Nailing - Results
Flynn et al. JPO Jan 2001
• 57/58 excellent or satisfactory
• No rotational malunions
• 6/58 – 1-2 cm LLD
36. 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
37. Flexible Nails
• Multiple studies from
multiple institutions
now report excellent
outcomes with few
complications
• If fracture pattern
allows this is the
preferred method of
fixation for many
38. 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
39. Why Not Use Rigid Nail?
Concern about AVN / osteonecrosis
of the femoral head
41. Piriformis Fossa Entry Site
Raney E. JPO, 1993.
Thometz J, JBJS 1995.
Astion D, JBJS 1995
42. 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
45. 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
# Pts. Avg Age Hosp stay Results
Spica 13 12 +8 30.5 d Malunion (4), >2.5 cm short (2)
Nail 12 14 +0 20.6 d Trochanteric Arrest (1)
46. 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)
47. Trends in Pediatric Femur
Fracture Management
• Much less frequent traction- casting
• Immediate spica if <5 years old
• Flexible nailing for patients 5 years old to
skeletal maturity
• External fixation, plate fixation less
commonly used
• Submuscular plating for certain fracture
patterns
48. Trends
• Trochanteric entry rigid
nailing- new designs,
large experience in some
centers
• Limited/minimal incision
plating 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
52. 12 yo 200 lb female – unstable fx
treated with flexible nails – healed
with 30 degree procurvatum malunion
53. 13 yo male hit by car
Initially 2 retrograde TEN
1 became prominent
Healed 5 cm short
Lengthened over nail Healed with equal LL
Courtesy of
S.H.Sims, MD
54. Trend Toward More
Invasive Treatment
• More high energy fractures
• Improved operative techniques
• Failed nonoperative treatment
• Simplifies patient care
• Psychological, social and financial reasons
55. Timmermann and Rab
JOT 1993
• “Most children with fractures of the femur
have a satisfactory outcome with any
reasonable form of treatment.”
Return to
Pediatrics Index
Notas do Editor
As depicted in this drawing, the epiphyseal blood supply traverses the piriformis fossa.
Chung, Ogden, and Truetta showed in separate studies that the lateral ascending branch on the anatomic ring at the base of the femoral neck provides the main blood supply to the lateral aspect of the femoral neck and to the lateral and superior parts of the capital femoral epiphysis.
This artery lies I close proximity to the most common point of entry of an IM nail.
Damage to this arterial system is the most commonly cited cause of AVN of the femoral head.
Now that the anatomy and technique are clear lets look at what the studies show.
1996 POSNA survey
6 case reports (1994-1997)
I will detial these.
13 published series including one prospective trial.Summarize in a table the finding and then focus on those with a complication of AVN
There are 13 published series.
From 1981 to 2000.
The first three I mentioned earlier for they compared IM nailing to conservative treatment.
KIRBY REEVES HERNDON
The next couple with the following compliaitons
Beaty , Buford and Stns had eports of AVN .
In the end, there are 334 patients that under went rigid IM nailing.
4 of these or a little more than 1% had documented AVN.
Lets look at those 4.
To evaluate the results of IM nailing in this specific age group of 10-15, Kirby (1981) compared closed IM nailing with a Kuntscher nail to traction plus casting. to conservative treatment
Herndon conducted a similar study in 1989.
Kirby’s was a retrospective study of the two methods used at two different hospitls in Seattle in the 1970’s.
His findings were 2 of the 13 in the non-surgically treated group had significant shortening. Both required corrective surgery.Non e of the 13 fractures in the nailed group had significant complications. No malunions occurred. No infections. One intraoperative issue was a splitting of the lateral cortex of the proximal fragment There was one case of an asymptomatic presumed arrest of the trochanteric apophysis.
FU was an average of 16 months
herndon retrospectively reviewed 44 patients that underwent treatment for shaft fxs. Seven malunions ocurred in the non op group. None occurred in the 21 fx treated by Im nailing.
Hospital stay was significantly shorter in the operatively treated group.
No premature growth arrest or AVN was noted in the surgical group.
FU averaged 24 months
Reeves reviewed 90 adolescents with 96 femur fx. 49 underwent rigid fixation (30 nails and 19 plates. 41 underwent traction and subsequent hip spica casting. There were no malunions, nonunions or infections in the operative group. However there were 4 delayed unions and 5 malunions in the traction and spica group
Also not e the psychological complications in the conservatively trated group.
. One patient in the operative in group had a plate break before healing and one had a transient peroneal palsy.
The authors concluded that surgical stabilization was superior to traction and hip spica casting.