monterey talk 96 er in office ortho

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Femur and Femoral Neck Fractures
International Medical Corp Basrah March, 2009
Scott A. Hoffinger, M.D. Mark C. Dales, M.D.
Childrens Hospital Oakland, California Swedish
Hospital, Seattle, Washington
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Pediatric Femur Fractures

• Often lower energy than adult
• Osteoporosis is adult issue
• Growth and AVN are femoral neck problems

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Levels of Fx

• Physeal
• Trans or Mid-cervical
• Basi-cervical
• Intertrochanteric

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Factors affecting outcome

• Level of fracture
• Energy of injury
• i.e. amount of displacement and vascular
  disruption
• Adequacy of reduction

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Blood Supply
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Blood Supply II

• Where the blood supply is intracapsular, vessels
  are highly at risk
• Easy to tear posterior vessels
• At base of neck, vessels are extra-capsular, safer

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Physeal Fractures

• Occur in very young patients
• Under age 1
• Or in teens and pre-teens
• SCFE

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Physeal Fractures

• Remember to think of inflicted injury, child
  abuse if under age 1 2

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Physeal Fractures

• Have no intra-osseous blood supply
• Rely on weak network of synovial vessels
• Can pressure cut this off?

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Physeal Fx AVN

• Difficult to show relationship with timing of
  reduction
• Seems to be initial injury to vessels
• Late fxs dont seem to get AVN, just malunion

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Physeal Fx Treatment

• Young children, under age 1, if minimally
  displaced can be treated with cast alone
• Forlin, JPO, 1992

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Forlin, JPO, 1992

• Young children often have delay in presentation
• IF delayed, do not reduce, does not increase AVN
• May get varus that remodels

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Young Physeal Fxs

• OR, deformity can be treated surgically when
  older
• Will they return for treatment?
• IF very displaced, and clearly acute, needs
  reduction, possibly with smooth pinning

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Older Patients Treatment

• Usu. dont present delayed
• Over age 4 5 years should be reduced, pinned
  (smooth), and then casted
• Minor degrees may not need reduction

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Physeal Fx Treatment

• Teens need pin stablization
• Like a SCFE
• IF unstable can reduce the acute component
• IS it a SCFE or a fx?

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Mid-cervical Fxs

• 45 of fractures
• Most common level
• 45 rate of AVN
• Usually high energy

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Pitfalls in Treatment

• Tendency to go into varus
• We often under-appreciate the instability and
• Fail to both internally fix AND cast

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Difficulty with fixation

• Physis limits fixation proximally
• Trochanter limits fixation distally
• Screw / sideplate seems too much

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Difficulty with fixation II

• If proximal, try to avoid physis BUT fx fixation
  takes priority
• If low, poor bone at intertroch. region
  compromises rigidity
• Dont forget the cast

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Young Neck Fxs

• Prefer to avoid physis
• If too little bone, may need to compromise physis
• ?smooth pins or remove threaded

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Non-displaced fxs

• If entirely non-displaced, can place spica only
  if young, or screws only if older
• May still go into varus
• If displaced at all, or high energy, fix and cast

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Type of fixation

• Cancellous screws
• 5.0 mm minimum
• Prefer 6.5 or 7.3 mm
• 3 screws if you can

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?Time to reduction

• Does immediate reduction matter very
  controversial
• In many cases, open surgery shows a torn capsule
• If capsule is torn, then capsule is decompressed

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?Time to reduction II

• If non-displaced, and capsule not torn, AVN less
  common
• Are there some fxs in which the intra-capsular
  bleed, in an intact capsule, is the vital
  difference?

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Femoral Neck Summary

• Difficult fractures with high potential for poor
  outcome
• Treatment varies by level

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Femoral Neck II

• Mid and base of neck fxs need aggressive
  treatment
• If any tendency to be unstable, both fix and cast
• Avoid varus deformity

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Femur Shaft Fx Options

• Immediate spica
• Traction and spica
• Flexible nailing
• Reamed nailing
• External fixation

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Length

• Shortening vs. overgrowth
• May be less of an issue if set out to length
• Still a variable
• We are probably making some kids too long

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Shortening II

• Acceptable is one shaft diameter, not more than
  two
• Mostly an issue if being casted or in traction
• Biggest problem with traction is too long!

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Under Age 5

• Almost always immediate spica
• Can go home from ER
• Double leg
• Feet out

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Traction

• Now procedure of choice only for subtroch fxs
• Under age 5
• Femoral pin for 21 days
• 2 fbs above patella
• Spica for 4 6 wks

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Traction and Spica II

• Always an option
• Never feel pushed to operate
• Results are quite satisfactory

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Spica Cast Tips

• Double vs 1½
• Keep feet out
• Dont flex knees too much

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Ages 6 10

• Flexible Nancy nailing
• Can use Enders or Nancy nails
• Usually two
• Usually retrograde

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Flexible Nailing

• Becoming standard of care for middle age children
• Simple to do
• Requires C-arm
• Hardware

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Flexible Technique

• Can do on fx table or lucent table
• Drape to include trochanter
• Lateral and medial distal incisions
• Avoid geniculate vessels

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Flexible Technique II

• Bend the tip of the first pin to help guide it
• Rotate pin as you insert
• AVOID opposite cortex penetration

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Flexible Nails II

• IF comminuted can use more than two
• Can even place from proximal through trochanter
• Same size nails
• Try for C and reverse C

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Hardware

• Our data suggests no need to remove flexible pins
  if no symptoms
• We therefore cut ends short
• If symptoms vague and rods removed, no change in
  sx

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Reamed Rodding

• Over age 12
• 10 12 is gray, but done if large enough
• Depends on size of patient, size of canal, energy
  of fx
• Need for rigidity

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Reamed Technique

• Tip of trochanter
• Not pyriformis fossa but also NOT too lateral
• Puts you OUT of line with medullary canal

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Reamed Technique II

• Use a nail that goes down to an 8 WITHOUT a big
  head
• Some question strength of an 8.5 nail with
  interlock holes
• Over-ream proximally 2 mm
• Stop short

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Too Lateral
A bit too medial
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Just right
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Vascular

• Femoral artery
• Medial femoral circumflex
• Lateral ascending cervical
• Posterior anastamotic ring
• Lateral epiphyseal artery

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K.I. 10 year old girl, hit by car
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13 year old boy, tackled playing football
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IM Rod, through trochanterdouble lockednot too
long
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Advised to walk at 6 weeks, when some callus
visible. Fx shortly thereafter. Converted to
plate
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Conclusion I

• Femoral shaft fractures in younger children can
  be treated in a spica cast
• Femoral shaft fxs over age 6 7 can be treated
  surgically

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Conclusion II

• Flexible nailing a good option under age 11 12
• Rigid nailing over that age