Lower Extremity Fracture Management Brian Brighton, MD, MPH Levine Children s s Hospital Carolinas Medical Center Charlotte, NC Oscar Miller Day October 16, 2009 Lower Extremity Fractures in Children Anatomic and physiologic variations between adults and children Closed management with casting results in good outcomes Important to know how and when to intervene with surgical management Lower Extremity Fractures Pediatric Hip Fractures Pediatric Diaphyseal Femur Fractures Fractures around the Knee Transitional Ankle Fractures Fractures of the Hip Relatively uncommon Less than 1% of all fractures in children and less than 1% of all hip fractures Majority are the result of high energy trauma Blood Supply of the Proximal Femur Vascular Anatomy < 4 months 4 months-3years Trueta, JBJS, 39-B, 1957 4-7 years Pre-adolescent 1
Delbet Fracture Classification Type I-I Transepiphyseal Type II- Transcervical Type III- Cervicotrochanteric Type IV- Intertrochanteric Type I Transepiphyseal Transphyseal fractures Occur more often in younger children May be caused by child abuse 50% associated with dislocation Risk of AVN high, especially with dislocation Malunion,, Premature physeal closure Hip Fractures Type II- Transcervical Most common 45-50% 50% Risk of AVN related to initial displacement (up to 43%) Treat with ORIF Hip Fractures Type III- Cervicotrochanteric AVN related to both fracture severity and amount of initial displacement AVN rate 20% Complications include coxa vara,, premature physeal closure, nonunion Hip Fractures Hip Fractures Type IV- Intertochanteric 11-17% 17% of hip fractures Far fewer complications than femoral neck fractures Treatment method variable, ranging from spica cast, traction, to ORIF Pediatric Diaphyseal Femur Fractures 2
Decision Making Pediatric Diaphyseal Femur Fracture Options Age Mechanism of injury Fracture pattern and location Associated Injuries Surgeon preference Flynn JM, Schwend RM. JAAOS 2004 AAOS Clinical Practice Guideline on the Treatment of Pediatric Diaphyseal Femur Fractures (PDFF) June 2009 Recommend that children younger than 36 months with a diaphyseal femur fracture be evaluated for child abuse (A) Treatment with a Pavlik Harness or a spica cast are options for infants 6 months and younger with a diaphyseal femur fracture (C) Suggest early spica casting or traction for children age 6 months to 5 years with a diaphyseal femur fracture with less than 2 cm of shortening (B) 3
Early sitting spica 3 part, 90-90 It is an option for physicians to use flexible intramedullary nailing to treat children age 5 to 11 years diagnosed with diaphyseal femur fractures (C) This technique, recommended in textbooks and articles, may increase risk of developing compartment syndrome Piriformis Fossa Entry Site Rigid trochanteric entry nailing, submuscular plating, and flexible intramedullary nailing are treatment options for children age 11 to skeletal maturity diagnosed with diaphyseal femur fractures, but piriformis or near pirformis entry rigid nailing are not treatment options (C) Astion D, JBJS 1995 Thometz J, JBJS 1995. Raney E. JPO, 1993. 9 yo male with left femoral shaft fracture 13 yo male with right femoral shaft fracture 4
Distal Femoral Physeal Fractures Distal Femoral Physeal Separation Classified by the Salter-Harris Classification Often occur with high energy injuries or sports related activities in older children SH I and II fractures may be treated with closed reduction and percutaneous fixation SH III and IV may require ORIF Complications include growth disturbance with limb length inequality or angular deformity Distal Femoral Physeal Separation Salter Harris II Distal Femur Fracture Salter Harris II Distal Femur Fracture Salter Harris II Distal Femur Fracture 5
Tibial Spine Fracture Pediatric ACL injury Anatomy ACL attaches to intercondylar eminence Mechanism of Injury sports bicycle Signs & Symptoms hemarthrosis lack extension (bony block) anterior laxity Imaging lateral knee x-rayx Classification Meyers & McKeever (JBJS 1959) Type I Type II Type III Tibial Spine Fracture minimal displacement hinged completely displaced Tibial Spine Fracture Recommendations Type I Fractures: long-leg leg cast: extension Type II & III Fractures: Aspiration & Reduction Nonreducible: ARIF Fixation Options Cannulated 3.5 mm Epiphyseal Screws Suture Tibial Tubercle Fracture Avulsion fracture of the tibial tubercle Fractures occur in boys ages 13-16 16 Occurs during athletic jumping activites Eccentric quadriceps contraction Tibial Tubercle Fracture I II Evaluation Check for active knee extension and Displacement of tubercle on lateral radiographs Classification Ogden modification of Watson-Jones classification based on location of fracture line and comminution III IV 6
Tibial Tubercle Fracture Beware of risk of compartment syndrome Branches of the anterior tibial recurrent artery that may retract laterally and distally Result in hematoma formation and increase the risk of developing compartment syndrome Pape et al. CORR, 1993 Common fracture among children and adolescents Mainstay of treatment in closed reduction and immobilization in a long leg cast Acceptable alignment <8 (10 coronal or sagittal plane, < 1cm shortening, complete translation ok) Older children (<5 of varus/valgus or sagittal deformity, < 5 mm of shortening, 50% translation Operative treatment for irreducible or unstable fractures, open fractures, polytrauma 7
Ankle Fractures Ankle Fractures Transitional Ankle Fractures During the transition time of physeal closure Physeal Closure Timing: begins to close Girls 12 years Boys 13 years Pattern of closure Central, then Medial, then Lateral Tillaux Ankle Fractures SH III Caused by external rotation CT scan often helpful Acceptable articular reduction of <2mm for closed treatment If surgery is required Closed reduction and percutaneous medial transepiphyseal or lateral transphyseal screws Open reduction via anterior arthrotomy with screw fixation 13 yo girl with ankle injury Tilleaux Fracture Triplane Ankle Fractures Multiplanar,, SH IV SH III on AP, SH II on lat CT scan often helpful Acceptable articular reduction of <2mm for closed treatment If surgery is required Open reduction performed through anterior approach with a transepiphyseal screw then screws in the metaphyseal fragment 13 yo girl with ankle injury S/P ORIF 8
Triplane Ankle Fractures Triplane Ankle Fracture Three part triplane fracture Two part triplane fracture 9