Overview : Pediatric Femoral and Tibial Fractures

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Overview Pediatric Femoral and Tibial Fractures

• Steven L. Frick, MD
• Pediatric Orthopaedics
• Carolinas Medical Center

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Timmermann and Rab JOT 1993

• Most children with fractures of the femur have a
  satisfactory outcome with any reasonable form of
  treatment.

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Decision Making

• Age
• Mechanism of injury
• Fracture pattern location
• Associated Injuries
• Surgeon preference

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Immediate or Early Spica Cast-ideal patient

• Less than 5 years old
• Less than 50 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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AAOS Managing Orthopaedic Malpractice Risk 2000

• Closed treatment of childrens femur fractures
  resulted in the most frequent and expensive
  complications, including foot drop, skin loss,
  compartment syndrome, and malrotation /
  shortening.

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Early 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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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, 90-90
This technique, recommended in textbooks and
articles, may increase risk of developing
compartment syndrome
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Current technique Above knee cast first. Hip
and knee- 40-45 flexion, foot out. Can include
opposite thigh if desired.
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Trend Toward More Invasive Treatment

• More high energy fractures
• Improved operative techniques
• Failed nonoperative treatment
• Simplifies patient care
• Psychological, social and financial reasons

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Goals Pediatric Femur Fxs

• Restore length, alignment, rotation
• Preserve growth potential
• Avoid osteonecrosis
• Minimize disruption of child / family life
• Minimize length of hospital stay

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Piriformis Fossa Entry Site
Thometz J, JBJS 1995.
Astion D, JBJS 1995
Raney E. JPO, 1993.
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ON
Ganz, et al
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Ambulatory Treatment Options

• Plate screw fixation
• External fixation
• Flexible nailing
• Rigid nailing
• Bridge plating / MIPPO/ locked plates

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Flexible Nails

• Titanium elastic intramedullary nailing (TEIN)
• popular choice to stabilize pediatric femur
  fractures in children gt 5 yrs
• little published on complications
• JBJS Br 2006

Initially 2 TEIN Healed 5 cm short
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Most complications minor
Nail Irritation (16) - dont bend
ends- all resolved post removal
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Cut pins above physis with screw cutter
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13yo male, 94 lbs -nails too short, back out, get
infected, have to be removed, varus malunion with
shortening
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12 yr old female, 130 lbs Varus, procurvatum
malunion
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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 (p0.55)
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Recommendations gt 11 years, gt 108 lbs
consider other treatment options
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Be wary of prox 1/3- mid 1/3 junction fracture
with medial butterfly
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Percutaneous Bridge Plating
Courtesy of E.M. Kanlic, MD, PhD
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Courtesy of E.M. Kanlic, MD, PhD
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Previous fracture with endosteal callus- plate
good option
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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 canal
  nonlinear
• Large diameter nail ? benefit (no reported nail
  fractures, nonunion rare)

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12 year old male, 6 mos
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Small diameter solid nail, unreamed
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Trochanteric entryProximal and distal
interlocking
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Leave some bone medial to nail
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Nail removal

• Some controversy
• Commonly recommended
• Survey studies remove IM devices in children
• Outpatient procedure
• Grasping pliers
• WBAT
• No sports for 4 weeks
• Return for xray 4 weeks post removal

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Summary

• lt 5 years early spica cast, changed technique
• 5-11 years, lt 100 lbs ESIN
• gt 11, gt 100 lbs trochanteric entry nail or
  bridge plating
• Very distal or very proximal fracture, closed IM
  canal, or severe axial instability bridge
  plating
• Severe soft tissue injury- external fixation

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Toddlers Fracture

• Very common in young children
• Accidental
• Stable
• Cast for three weeks

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Isolated Tibia Fracture With Intact Fibula

• Often at middle/distal third
• Muscle forces/biomechanics usually result in
  drift into varus angulation
• Valgus mold in initial cast
• Can wedge at 2 weeks but more difficult because
  of intact fibula

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Isolated tibia fracture casted with valgus mold
healed with excellent alignment
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Low energy fracture- cast
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High energy closed fracture- TEIN
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Compartment Syndrome

• Can occur in skeletally immature patient after
  closed or open tibia fracture
• Think about it- DONT MISS

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12 year old, pedestrian vs carFloating knee
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Healed floating knee
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Ex fix higher malunion rates than TEINs
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Open tibia fracture with soft tissue deficits
Appropriate pin placement and construct needed to
control varus
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Open tibia fractures- ID, flexible nailing
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Tibia Fracture Malunion/Nonunion
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www.ota.org

• Orthopaedic Trauma Association website
• Resident Curriculum slides
• Pediatric fractures 13 powerpoint lectures

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Filling a Growing Regional Need for Access to
Pediatric Care