PAEDIATRIC HIP AND FEMUR FRACTURES DR.RAVI VARMA.V.N MODERATOR-DR.MRUTHYUNJAYA
PAEDIATRIC HIP AND FEMUR FRACTURESDR.RAVI VARMA.V.NMODERATOR-DR.MRUTHYUNJAYA
HIP FRACTURES•Very rare compared to adult hip fractures•Less than 1% of all pediatric fractures•80-90% due to high energy trauma
Difference from adults•Anatomy•Proximal femoral epiphysis is at a risk of
fracture•Smooth Fracture surfaces, with very little
interlocking impaction closed reduction less stable.
•Blood vessels to the femoral head are easily damaged, and a high incidence of AVN occurs in fractures in children than adults.
•Growth arrest in the physis can cause shortening of up to 15% of the total extremity
• Varus or valgus angulation of the femoral neck also can occur from arrest of only one side of the physis.
•A child can tolerate immobilization much more readily than an adult, and thus more choices for treatment are available, including traction, a spica cast, and bed rest, in addition to operative treatment.
•Fixation devices causes growth arrest.
Mechanism of injury•Severe High energy trauma•Always associated with other injuries-
careful evaluation is a must•Minor injury suspect pathologic
fractures(unicameral bone cyst,osteogenesis imperfecta,fibrous dysplasia,myelomeningocele,osteopenia due to polio)
Applied anatomy•Proximal femur has single physis at birth•Separates into two distinct centers of
ossification capital ephiphysis trochantric apophysis•Ossification of femoral ephiphysis
between 4 to 6 months•Ossific nucleus of greater trochanter
appears at 4 years
•Lesser trochanter at 10 years•Trochanteric physis growth arrest at 16-
18 years•Proximal femoral physis at 18 years•Neck shaft angle is 135 degree at birth•145 degree at 1 to 3 years •Gradually matures to 130 degrees at
skeletal maturity
•Femoral anteversion is 30 degrees at birth and ranges to 10.4 degrees at skeletal maturity
•Growth arrest causes abnormal neck shaft angle,femoral anteversion and a reduced articulotrochantric distance
•Mild limb length discrepency as it contributes approximately 15% of growth of extremity
Blood supply to proximal femur•Two major arteries medial circumflex(major) lateral circumflex•Extracapsular ring•Intracapsular ring•Lateral cirumflex supplies lateral and anterolateral of GT anteromedial of femoral head till 5 to 6 months anterolateral
physis
Profunda femoris
Medial circumfle
x
Posterior inferior
Posterior superior
Lateral circumfle
x
transverse
Ascending
descending
Medial circumflex is the major supply of proximal femur
•Travels posterior to iliopsoas tendon•Continues along medial side of femur
between inferomedial capsule and LTSupplies•Postromedial ephiphysis•Posterior physis•Posterior aspect of GTThe artery of ligamentum teres supplies
small area of femoral head(20%) continues to adulthood,branch of obturator(80%) or medial circumflex(20%)
•At 15 to 18 month blood vessels crossing physis gradually disappear
•By end of 3 years entire blood supply of proximal femoral ephyphysis from lateral ephiphysial vessels( br of medial circumflex)
•These vessels stay external at level of intertrochantric level
•Traverse the capsule within retinacular folds hence should be careful during capsulotomy
•This supply continues to adulthood
•Unique vascular supply to CFE makes immature hip vulnerable to growth derangement & subsequent deformity after a fracture.
DELBET CLASSIFICATION
•TYPE I : Transepiphyseal separation I A : With dislocation II B: With out dislocation.•TYPE II : Transcervical fracture•TYPE III : Cervicotrochanteric fracture.•TYPE IV : Intertrochanteric fracture.
TYPE 1-TRANSEPHIPHYSEAL•Acute traumatic separation of a
previously normal physis•<10% of peadiatric hip fractures•Similar to salter harris type 1•Differenciated from SCFE by age of
onset,onset of pain,severe trauma,more displacement
•More common in <2 years and 5 to 10 years
mechanisms•In a new born during a difficult breech
delivery [proximal femoral epiphysiolysis] mistaken with DDH.
•Following post reduction in post dislocation of hip
•High energy trauma•Child abuse
•Presentation is late•Associated with dislocation(50%)•Associated with other injuries•Result of treatment are poor
TYPE 2-TRANSCERVICAL• Fracture through mid
portion of neck• Most common 50% of
paediatric hip #• Severe trauma• 50% go to AVN as the
fracture is usually displaced at presentation
• Incidence of AVN related to initial displacement.
TYPE 3-CERVICO TROCHANTRIC• Fracture through the
base of femoral neck• 25-35% incidence• AVN 20-30%• Premature physeal
closure 25%.• Coxa vara 14%.
TYPE 4-PERITROCHANTRIC• Fracture between
greater and lesser trochanter
• 6-15% incidence• Lowest complication
rate• Good healing.• Nonunion & AVN
rare.
others•Proximal metaphyseal fractures in new
borns-confused with SCFE and dislocations
•Stress fractures-20 cases in literature
Clinical features•Severe pain/cry•Examine for associated injuries•Conversely look for hip fractures in other
injuriesOn examination•Injured limb in lateral rotation and adduction•If associated with dislocation classically
present with that deformity•Tenderness,painful movements•Be careful in non displaced fractures-limp
RADIOGRAPHY-X RAYS•AP and lateral views•Classify according to delbet•Look for displacement and ephyphysis•Trabecular pattern-Any Break or offset of
bony trabeculae near Ward’s triangle impacted #.
•Compare to the normal side
RADIOISOTOPE SCAN•Non displaced fracture and stress
fracture•Must be delayed after injury-for increased
metabolism(48-72 hrs)
MRI•Best for non displaced and stress
fractures•Better accuracy•Early diagnosis•No radiation•Shorter stay at hospital•Additional information of femoral head
viabilty,presence of bone cysts
TREATMENT•Age•Type•Displacement•Fracture lineRESULTS IN young(<8yrs),nondisplaced,type 3 and 4
are better thanolder,displaced,type 1 and 2
TYPE 1 TREATMENT•Due to high rate of complications•Anatomic reduction and rigid internal
fixation •Followed by cast immobilization is to be
followed
•Check for PFE if displaced out of acetabulum, if so,flex,slightly abducted and internally rotated under fluoroscopy guidance and closely reduced
•After reduction,internal fixation performed through lateral incision
<4 years-smooth krischner wires 4 to 7years-4.0mm cannulated screws older child-5.0 to 6.5 mm cannulated
screws
•A single attempt at closed reduction•Multiple attempts may predispose to AVN•Open reduction-mostly dislocated posteriorly
so modified southern moore approach to be done
if anterior smith peterson or watson jones approach to be used and fracture fixed internally
•Post fixation child is immobilized in one one and half hip spica cast with hip in neutral extension,30 degree abduction and 10 degree internal rotation
•Immobilized for 6 to 12 weeks•<2 years closed reduction and spica casting
alone can be done
TYPE 2-TREATMENT•Anatomic reduction & stable IF always
indicated to minimize risk of complications.
•Reduction by traction in extension and abduction and slight internal rotaion with downward pressure on GT and internal fixation as earlier by lateral approach
•Open reduction Watson & Jones approach
Sugical recommendations•Screws to be inserted short of physis.•If not good purchase penetrate the physis.•Treatment of # is priority, growth
disturbance & LLD are secondary•In older children 2 parallel screws must
be placed
TYPE 3 TREATMENT•Similar to type 2•Due to more distal fracture doesn’t afford
good purchase,hence casting has to supplement
TYPE 4 TREATMENT•Best outcome •Can be treated non operatively <6
years,regardless of displacement.•Indications for Internal fixation - failure to maintain reduction - polytrauma - older children
SURGICAL TIPS•Always predrill & tap before inserting
screws.•Avoid crossing the physis but cross it if
necessary for stability.•Postop, hip spica for 6-12 wks if < 10 yrs,
Stess fractures• Repetitive cycle loading of hip by new or
increased activity, in a pathologic or normal bone• Adolescent female athlete, anorexia nervosa, &
osteoporosis.• X rays only reveal after 4-6 wks• DEVAS classification1. Compression - non wt bearing, coxa vara. 2. Tension – inherently unstable, insitu fixation
• Can be managed conservatively• Non wt bearing• Cast in non cooperative child• Weight bearing only after complete radiological
union
COMPLICATIONS1. AVN2. COXA VARA3. NON UNION4. PREMATURE PHYSEAL ARREST5. INFECTION
AVASCULAR NECROSIS•Most serious & most frequent•Overall prevalence 30%.•Primary cause of poor results.•Highest in type I>II> III>IV•Initial # displacement, damage to blood
vessels, # hematoma are the factors
PREVENTION•Early treatment•Aggressive operative management•Decompressive hip arthrotomy-needle
aspiration(subadductor approach) followed by internal fixation of fracture
Clinical features and radiology•Early pain in the groin•Radiological features seen as early as 2
monthsFeatures•Osteopenia of femoral head•Followed by sclerosis,fragmentation,often
collapse and deformityMRI is most sensitive and confirms the
diagnosisRADIOISOTOPE scanning with steel
implant-decreased uptake
RATLIFF CLASSIFICATION•TYPE I : Involvement of whole head - most severe & most common form - worst prognosis -damage to all lateral epiphyseal
vessels•TYPE II: Partial involvement - localized damage to one or more
LEV.•TYPE III: an area of AVN from # to physis - damage to superior metaphyseal V. - rare but good prognosis.
TREATMENT AND PROGNOSIS•Treatment is unsuccessful•Limited data available hence defining the
superior modality is difficultGOALS OF TREATMENT•Preserve the functional range of hip•Maintain containment of femoral head in
acetabulum•Preserve as much as femoral head
viability as possible
•Treatment should begin at the onset of symptoms and should stress on non weight bearing or partial weight bearing
•Operative-1st is to remove the implant Intertrochantric valgus osteotomy Core decompression with fibular grafting Capsulotomy Arthrodesis Arthroplasty
Coxa varaCauses•Malreduction•Loss of reduction•Delayed and non union•Premature closure of ephiphysis(GT
overgrowth)Incidence 10-32%•Highest in closed reduction and external
immobilization•Lesser in internally fixed
•Obliquity of fracture(pauwels angle <50 degree)
•< 100 degree of neck shaft angle and older children have high incidence of varus
Preventive measures•Internal fixation with cast immobilization•Avoid screw crossing growth plateTREATMENT•Valgus osteotomy(subtrochantric valgus
osteotomy)
NON UNION•Incidence 6.5%-12.5%•Poor reduction•Distraction of fracture fragments•Time of internal fixation•Pauwels angle >60 degreeNon union can lead to other complicationsPrevention by means of anatomic
reduction,internal fixation and external immobilization is important
treatment•<10 years autogenous bone grafting and
rigid internal fixation in lag fashion•Older child subtrochantric valgus
osteotomy-goal is to alter plane of fracture to produce compressive loads across fracture site and followed by blade plate fixation
PREMATURE PHYSEAL ARREST•Incidence 10-62%•Amount of displacement at time of injury•The development of AVN•Internal fixation crossing physis•More number of pins for fixationNo significant deformity or limb length
discrepencyBut if combined with AVN causes it in all
cases
Preventive measures•Gentle closed reduction•Smooth pin fixation in young child and
cannulated screws not crossing physis(fracture stability not compromised)
•Serial scanograms and bone age measurements done to predict limb length discrepency
•Moseley line graph used to accurately predict timing of contolateral ephiphysodesis
INFECTION•Very rare 1%•Associated with AVN•Treatment –debridement,IV antibiotics
FEMORAL SHAFT FRACTURES
ANATOMY AND DEVELOPMENT•Femur appears at 4th week of gestation•8th week enchondral ossification begins•Primary center is femoral shaft•Secondary center proximally at 6 month•Distal secondary center at 7th fetal month•The femur shaft grows initially by enchondral
ossification•Production of medullary cavity with
calcification in the periphery and vascularization in center results in a large primary ossification center
•Woven bone for 18 months later lamellar type
•Blood supply is from both endosteal and periosteal blood vessels
•Endosteal derived from two nutrient arteries enter femur from posteromedial direction
•Periosteal supply outer 25% of cortical bone more near muscular attachments
•Two systems with metaphyseal complex interconnected to provide strong supply,hence rapid fracture repair
Mechanism of injuryAge dependent•Child abuse before walking age 70% Appropriate examination,rule out other
injuries,later presentation
•Adoloscent –high velocity injury waddles triad-femur fracture with
head and thoracic injuries
Differnces from adult•Pulmonary complications are rare with
multiple injuries and timing of intervention doesn’t affect
•Minor trauma should alert pathology(osteogenesis imperfecta,osteopenia of cerebral palsy,myelomeningocele,aneurysmal bone cyst,unicameral bone cyst very rarely ewings and malignancies
CLASSIFICATION•WINQUIST AND HANSEN
CLASSIFICATION
Fracture discription•Condition of soft tissue•Location of fracture•Configuration•Angulation•Shortening- >3cm is unacceptable•Winquist helps in classifying
communition-useful in nailing
Clinical features•Localised tenderness,crepitus,abnormal
mobility and deformity•Look for ecchymosis around hip to rule
out ipsilateral and contolateral hip fractures
•Neurologic and vascular examination(rare)
Radiology•AP and lateral views of entire
femur,hip,knee•Thomas splint manipulated and xray
taken•Look for fracture
pattern,diplacement,communition•Stress fractures need CT and MRI
evaluation•Intraarticular fractures and dislocation
needs CT•angiography
TREATMENT•Result of high energy trauma•Multidisciplinary team approach
necessary•Age,mechanism,diplacement,soft
tissue,social life
TREATMENT OPTIONS• Traction• Spica Casting• Pins & Plaster• External Fixation• Internal Fixation
▫Plate/Screws▫Flexible nails▫Rigid Intramedullary rods - trochanteric
vs. lateral entry
• Treatment is often directed by the patient’s age
▫0-6 months▫6 months - 5
years▫5 - 11 years▫11 years -
skeletal maturity
0 - 6 Months•40% of femoral diaphyseal fractures in
patients <1 year of age are non-accidental
•Child Abuse - >90% of pediatric femoral shaft fractures resulting from abuse occur in children <36 months of age
0-6 months• Pavlik harness
▫Stable union typically achieved within 5 weeks
• Spica casting▫Higher risk of skin complications than
Pavlik▫Waterproof cast liners improve sanitation
• Spica casting with incorporated distal femoral traction pin
▫May decrease incidence of unacceptable shortening and frontal plane malalignment
6 months to 5 years▫Diaphyseal Femur
Fractures: <2cm shortening
Early spica casting (90°/90°)▫Enhanced ease of care▫Shorter hospital stay▫No defined optimal weight range
Traction with delayed spica casting▫Skin traction typically ineffective; skeletal traction often required
• Diaphyseal Femur Fractures:▫> 2cm shortening
Spica casting Insufficient evidence to recommend
for/against (AAOS Clinical Practice Guideline)
External fixation Lower incidence of malunion
compared to spica casting Flexible IM nailing may be considered
for the oldest, most mature patients in this age group
• Insufficient evidence exists to recommend any specific degree of angulation, rotation, or shortening that is unacceptable (AAOS Clinical Practice Guideline)
▫Traditionally: Varus/valgus deformity more poorly
tolerated than flexion/extention deformity Up to 30° of rotational malunion can be
tolerated Remodelling occurs to a greater extent in
younger children with more growth potential
Overgrowth is a biologic response to fracture in this age group but is unpredictable
5-11 YEARS• Skeletal Traction
▫Typically used to precede definitive treatment particularly in severely traumatized patients
• Spica casting▫Poorly tolerated, ▫Higher risk of malunion
Flexible (Elastic) Intramedullary Nails
▫ Preferred method for treatment of most femoral disphyseal fractures in this age group
▫ Load sharing capability▫ Titanium or stainless steel (Enders)▫ Antegrade or retrograde (more common) insertion▫ Outcomes best when used to treat stable fracture patterns▫ Shorter hospital stay▫ Fewer adverse events▫ More rapid return to school▫ Most common complication is irritation at distal insertion
sites
•Avoids more proximal insertion and thus avoids AVN
•Used in 6 to 16 years though used<4 years
Procedure-•2 flexible nails of equal diameter should
be used to allow 3 point fixation•A single entry point is used laterally with
c shaped rod ending in metaphyseal region of GT and s shaped ending till mid portion of neck
•Should be kept till union is seen radiologically
•Removed within a year as removal becomes difficult later
11 YEARS TILL MATURITY• External Fixation
▫ Useful to achieve provisional fixation of femoral fractures in severely injured patients or open fractures
▫ May be used for definitive treatment of subtrochanteric or distal metadiaphyseal fractures that are less amenable to plate or nail fixation
▫ Avoids direct fracture exposure, minimizes blood loss, minimizes risk of physeal injury
▫ More frequent complications include delayed union,pin tract infections and refracture after device removal
•Compound fracture•Disruption of tissue•Multiple trauma•Arterial injury•Unstable pattern•Failed conservative management
• Flexible intramedullary nails▫Outcomes optimized when use is limited to
stable fracture patterns▫Higher risk of complications in patients
>11 years of age, >108 lbs (49kg), and unstable fracture patterns
▫Commonly reported complications: knee pain at insertion site, nail prominence, nail migration, fracture shortening/malunion, delayed union
Submuscular plating• Limited approach with indirect fracture reduction• Useful in communited fracture and unstable
fractures• 12-16 holed lcp inserted submusculary and
superficial to periosteum through 2 cm incision over proximal and distal metaphyseal flare
• Reduced by traction and unstable portion is bridged
• Under fluroscope,screws placed percutaneously by stab incision
•Union by 12 weeks•Technically demanding
• Rigid intramedullary nailing - greater trochanteric entry femoral nail
▫Well suited for unstable fracture patterns▫Patients >108lbs (49kg) who are not
candidates for flexible IM nailing▫Piriformis or near-piriformis entry nailing is
NOT a treatment option Risk of injury to the lateral ascending
cervical branches of the medial femoral circumflex vessel in the piriformis fossa
Increased risk of femoral head osteonecrosis (≥4%)
▫Risk of coxa vara due to trochanteric apophyseal growth arrest
▫Permits rapid mobilization
• Rigid intramedullary nailing- lateral entry femoral nail
▫Similar indications to trochanteric entry nails
▫Designed to avoid injury to circumflex vessels and trochanteric apophysis
TREATMENT TECHNIQUESSKIN TRACTION-•Non invasive used in 2 situations small child with shortening >3cm to allow
spica casting child who is to undergo definitive skeletal
fixation on a delayed basis•Bryant’s traction <2 years-overhead traction
with hip in 90 degree and knee extendedVascular insufficiency is a common complication,
Skeletal traction-•Older child with diaphyseal fracture when
more than 5-10lb weight required•Distal femur is the best site parallel to
knee•If soft tissue injury then at proximal tibia
after ruling out knee injuriesTraction should reduce within 2 cm in
younger child and end to end in older child
Continued till callus formation 2-3 weeks
Spica casting•Immediate casting advised in•Stable shaft fracture•<3mm shortening•<8years•Without massive swellingIf not a period of traction used
•The cast should be placed with child's hip flexed approximately 60-90 degrees(the more proximal fracture more is to be flexed)
•30 degrees of abduction•Knee flexed to 90 degrees•Some external rotation will correct the deformity•Applied on a spica table•Applied when assistant holds fracture in
reduction•Take care of compartment syndrome
•Radiographs taken before hardening for manipulation
•Acceptable alignment depends on age•Not more than 15 degree deformity in
coronal plane•And 25-30 degree in sagittal plane•Shortening not >2cm•Serial radiographs•Wedging for correction of angular
deformity
COMPLICATIONS•Limb length inequality•Unacceptable angulation•Rotational deformities•Non union and delayed union•Compartment syndrome•Infection inflammation•Vascular injury
Limb length inequality•Due to overgrowth or shortening at
fracture site•Due to this ideal reduction should have
1.5 to 2cm shortening•Treatment of excessive shortening
depends on time of recognition•Hip spica to be removed re traction and
application•If callus has formed osteoclasis followed
by external fixation
angulation•Depends on•Age•Proximity of fracture to physis•Plane•Younger children,fracture near physis and
deformity in the plane of motion good remodeling potential
•25 degree acceptable•If significant, corrective osteotomy close to
apex of deformity and rigid fixation is done
ROTATIONAL DEFORMITIES •Have less remodeling than angular•15 to 25 degree well tolerated•Most severe require corrective surgery
NONUNION AND DELAYED UNION•Very rare •Nonunion treated by bone grafting with
rigid fixation•Delayed union external fixator with
dynamization
COMPARTMENT SYNDROME•Very rare in thigh to to high muscle mass•Risk factors in prolonged Bryant's
traction,direct trauma•fasciotomyINFECTIONINFLAMMATION VASCULAR INJURY
DISTAL FEMORAL INJURIES
ANATOMY•Formed from single ossific nucleus, first
present at birth and is first epiphysis in body to ossify
•Grows at a rate of 8-10 mm per year•Contributes 40% of growth of lower
extremity•Closes at 13 in girls and 15 in boys
•The distal femur has a classic rhomboid shape and inclination of joint line at knee
•Anatomic axis-9 degree•Mechanical axis-3 degree
•The muscular attachment of gastrocnemius and plantaris is on posterior aspect of distal femoral metaphysis,proximal to physis,hence flexion
•Adductor magnus attached to medial aspect of femoral metaphysis,hence varus
•Collateral ligaments attach at the level of epiphysis
Mechanism of injuryAGE•Newborn period-breech presentation-type
1 SA •In 3-10 years, severe trauma, rarely
sports injuries•In adolescents more of sports injuriesDIRECTION OF FORCE•Valgus type of force•Hyperextension force
CLASSIFICATION
CLINICAL FEATURES•Acute distress secondary to pain•Knee is in flexed position•Deformity•Ecchymotic areas indicate deforming
forces•Look for swelling in popliteal region•Neurovascular examination is the must
radiology•Xrays•Stress views•ct•Mri •Ultrasound•X-rays should be compared with
contralateral physis
TREATMENTDISTAL FEMORAL METAPHYSEAL
FRACTURE•Closed reduction,percutaneous pinning
and cast conversion is preferred•Anatomical reduction with acceptable
residual angulation in sagittal plane 20 degrees <10 degree in child
•No rotational misalignment accepted•<5 degree varus and valgus
External fixation•Soft tissue injury with open fracture•Poly trauma patient with urgent
satbilizaation•Highly communited fracture •Fracture is reduced primarily•With two pins proximal to fracture site and
two pins in the distal metaphyseal fragment• Placed atleast 1cm away from physis and
parallel to knee joint line from lateral•And fluoroscopically checked in extension
and realigned if any malalignment
•Partial Weight bearing started depending on the stability
•After mature callus is formed immobilzed in walking cast or dynamization of ex fix done
•With highly communited fracture spanning of knee joint with 2 pins 3cm distal to tibial tubercle,
•In such case tibial pins to be removed to allow knee rom after 4 to 6 weeks
CLOSED REDUCTION AND INTERNAL FIXATION
•hyperextension type of injury-distal fragment is flexed by pull of gasrtocnemius and proximal fragment is posteriorly placed
•Hyperflexion type-distal fragment is flexed and proximal fragment is anterior
• Reduction is difficult as plane of motion and plane of displacement in same direction
• And inadequate lever arm of distal fragmentHyperextension type-hip and knee flexed to relax
quadriceps and hamstrings• Longitudinal traction applied with increasing
flexion of knee to bring distal fragment posteriorly• Distal fragment pushed posteriorly and proximal
fragment anteriorly• With knee flexed to 60 degree and reduction
checked
•Hyperflexion type-axial traction with knee in extension,posterior distal fragment pushed anteriorly and proximal fragment posteriorly
•Once reduction achieved 2 threaded pins placed in cross fashion as far as from physis
•And external immobilization with spica cast hip in 60 degree or long leg cast with hip in 30 degree flexion depending on stability
•Knee in 60 degree flexion for 2-3 weeks and bought to extension later
OPEN REDUCTION AND INTERNAL FIXATION
•Irreducible•Require stable fixation such as arterial
injuryM0st common reason for failure is proximal
fragment buttonholing of the quadricepsStandard lateral approach , if arterial
injury then medial approach
DISTAL FEMORAL PHYSEAL FRACTURESTREATMENT PRINCIPLES•All attempts to closed reduction to be
performed under GA or sedation•Reduction maneuvre,predominantly traction
followed by manipulation•Not be performed for >10 days injury•Anatomic reduction to be achieved
especially in type 3 and 4•Internal fixation should avoid physis and
should be non threaded if crossing physis
NOTE- salter and colleagues stated that when excessive ,manipulation appears to be necessary to achieve acceptable reduction,it is better to maintain growth potential and perform corrective osteotomy at a later date than overstress to physis
SA TYPE 1•New born treated by immobilization-
remodelling•Older child closed reduction with
immobilization with cast•Older child with unstable requires smooth
pins or wires removed at 4 weeks and immobilized further
SA TYPE 2•75% are displaced more in juvenile•Non displaced and mildly displaced
fracture successfully treated by closed reduction and immobilization
•With reduction under GA and mainly traction and followed by reduction of angulation with a cast long leg in knee 30 degree extension
•With ligament injury reduction not tried and requires internal fixation
•Displaced type closed reduction under GA with percutaneous fixation of metaphyseal fragment with k wires/ccs
•Followed by immobilization in long leg cast in knee 30 degree flexion
•If closed reduction fails due to periosteal or muscle interposition open reduction planned
SA TYPE 3•Usually displaced and rare•Requires open reduction an internal
fixation•Followed by immobilization with knee in
30 degree flexion•Anatomical reduction to preserve
articular surface
SA TYPE 4•Similar to type 3•Both metaphysis and epiphysis should be
fixed
PROGNOSIS•Of these fractures depends upon •Age •Displacement(strong predictor)•Adequacy of reduction and fracture
stabilization•Type of fracture•Type 1 and 2 have better outcome
complicationscomplicatio
ns
acute
Arterial injury
Peroneal nerve injury
Ligamnetous injury
Loss of reduction
late
Physeal arrest
Angular deformity
Loss of knee motion
ARTERIAL INJURY•Rare in distal ephiphyseal injury•Common in complete separation of physis
in a hyperextension injury•Injury to the arterial wall only 3 cases
reported•Hence after reduction in case of
discrepency btw two limbs pulse is checked
•Arterial injury requires stable fixation via medial approach
•Fasciotomy if needed
Peroneal nerve injury•Direct trauma on posterolateral aspect of
leg•Varus producing injury causing over
stretching•All injuries resolve by 6 month period •If no improvement for 3 months NCV to
be done and explored and nerve grafting or direct repair
Ligamentous injury•Most commonly involved is ACL followed
by LCL then MCL•Even meniscal injury possible• it is difficult to diagnose at time of injury
and should be evaluates soon after union
Loss of reduction•Due to suboptimal stabilization of
unstable fracture•Not immobilized in cast•No flexion in anteriorly displaced •No extension in posteriorly
Physeal arrestRisk factors•High energy trauma•Juvenile age group•Severly displaced fractures•Communited fractures
•Physeal fractures thoroughly evaluated by CT
•Physeal bar resection when <50% physis is involved and the growth remaining is atleast 2.5cm
•Limb lengths should be plotted on moseley straight line graph over a 1 to 2 year period to determine the projected discrepency at skeletal maturity
•No treatment is indicated if <2cm of discrepency
•Between 2 to 6 epiphyiodesis of contralateral distal femur or proximal tibia
•Large discrepency should be treated by femoral lengthening procedure
ANGULAR DEFORMITY•Less seen than limb length discrepency•Risk factors and indication for physeal bar
resection are the same•Treatment indicated >5 degree of
abnormal angulation is present consists of angular corrective osteotomies or ephysiolysis
Loss of knee motion•Excessive duration of immobilization•In SA type 3 and 4 due to articular
incongruitiesPrevented byRestricting the duration of immobilizationRemoving k wires as soon as possibleanatomic redution of intrarticular fractures
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