Complications of Pediatric Femoral Shaft and Distal Physeal Fractures

William P. Bassett, BA Shannon Saﬁ er, MD Martin J. Herman, MD Scott H. Kozin, MD Joshua M. Abzug, MD

Abstract Fractures of the femoral shaft comprise about 1.6% of all bony injuries in children and are the most common pediatric orthopaedic injury that requires hospitalization. The treatment of femoral fractures in children is largely dependent on the child’s age and size and takes into account multiple considerations: the child’s weight, associated injuries, the fracture pattern, the mechanism of injury, institutional or surgeons’ preferences, and economic and social concerns. In addition, during the past two decades, there has been a dramatic change favoring surgical ﬁ xation rather than casting because of the many advantages of ﬁ xation, including more rapid mobilization. The goal of treatment should be to ultimately obtain a healed fracture and avoid associated complications, such as nonunion or delayed union, angular or rotational deformity, unequal limb lengths, infection, neurovascular injury, disruption of the growth plate, muscle weakness, and/or compartment syndrome. Instr Course Lect 2015;64:461–470.

Fractures of the femur are common in- for these fractures include a healed frac- injuries in children and are the most juries in pediatric patients. This chapter ture and avoiding complications. common pediatric orthopaedic injury discusses fractures of the femoral shaft that requires hospitalization. Femoral and distal femoral physis. At these lo- Femoral Shaft Fractures shaft fractures in children are more cations, there is a substantial risk for Fractures of the femoral shaft com- common in boys and follow a bimodal complications. The goals of treatment prise approximately 1.6% of all bony age distribution, with the fi rst peak occurring during the toddler years and a Dr. Safi er or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf second peak in adolescence. Toddlers of Orthopediatrics and serves as a paid consultant to or is an employee of Orthopediatrics and Medicrea. Dr. Herman or an immediate family member serves as a board member, owner, offi cer, or committee member of the American Academy and young children are most com- of Orthopaedic Surgeons and the Pediatric Orthopaedic Society of North America. Dr. Kozin or an immediate family monly injured from simple falls, such member serves as a paid consultant to or is an employee of Checkpoint Surgical and serves as a board member, owner, offi cer, as tripping while running or a fall from or committee member of the American Society for Surgery of the Hand. Dr. Abzug or an immediate family member serves as a paid consultant to or is an employee of Axogen. Neither Mr. Bassett nor any immediate family member has received a low height. Older children and adoles- anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly cents sustain fractures most commonly to the subject of this chapter. from higher-energy injuries, with nearly

90% of the femoral fractures in older including osteogenesis imperfecta; dis- Orthopaedic Surgeons’ guideline for children resulting from motor vehicle use osteopenia in children with neuro- the treatment of pediatric diaphyseal crashes.1,2 muscular disease, such as cerebral palsy; femoral fractures is, in the opinion of Child abuse is another etiology of myelomeningocele; and neoplasms.1,2 this chapter’s authors, a good algorithm femoral fractures. Battered children of- for treating most patients.7 ten present fi rst with a fracture, and it Treatment Options is estimated that orthopaedic surgeons The treatment of femoral fractures Goals of Treatment see 30% to 50% of abused children. in children is largely dependent on a The goals of treatment should be to Consequently, orthopaedic surgeons are child’s age and size. Any treatment ultimately obtain a healed fracture and often responsible for distinguishing in- decision, however, involves multiple avoid associated complications, such tentional from unintentional injuries in considerations: the child’s weight, as- as nonunion or delayed union, angu- young children. Up to 60% of fractures sociated injuries, the fracture pattern, lar or rotational deformity, unequal seen in child abuse are isolated injuries, the mechanism of injury, institutional leg lengths, infection, neurovascular and the most common bone fractures or surgeons’ preferences, and economic injury, disruption of the growth plate, are of the femur and the humerus. and social concerns.4,6 Although fem- muscle weakness, and/or compartment Long-bone diaphyseal fractures are the oral diaphyseal fractures can create syndrome.1,2,4 Each primary treatment most common fracture patterns seen in substantial short-term disability, these modality has associated complications intentional injuries.1,2 These fractures injuries can be successfully treated with that will be discussed in detail. are seen at least as often as the typical a variety of interventions. The scien- epiphyseal-metaphyseal fractures (cor- tifi c literature provides little evidence Spica Casting ner or bucket-handle fractures) that are in terms of supporting one method of The current standard of care for young thought to be more pathognomonic treatment over another because the out- children aged 6 months to 6 years with of abuse.1-4 Before walking age, up to comes in this population are believed an isolated femoral diaphyseal fracture 80% of femoral shaft fractures may be to be good if an accepted method of is the application of an immediate hip caused by abuse. In a study by Coffey treatment is executed effectively.6 In spica cast within 24 to 48 hours. Ear- et al5 of more than 5,000 children at the past, the standard of care for most ly spica casting is ideally indicated for a trauma center, only 1% of the lower pediatric diaphyseal femoral fractures femoral shaft fractures, with as much as extremity fractures in children older was either casting or traction followed 20 mm of initial shortening. The cast than 18 months were caused by abuse, by casting. In the modern era, however, is generally worn for a period of 4 to whereas child abuse was the direct casting is used primarily for younger 8 weeks. The advantages of an imme- cause in 67% of the fractures in chil- children who have a substantial capacity diate spica cast include relatively low dren younger than 18 months. Other to undergo remodeling.4 cost, low complication rates, and a very investigators have reported that 65% The change in care plans for chil- high rate of achieving union with prop- of the femoral fractures occurring in dren and adolescents away from casting er alignment.1,2,8,9 infants younger than 1 year were caused toward fi xation has occurred during the However, the primary disadvantage by abuse, with a much lower incidence past two decades. Pediatric orthopae- of the immediate spica cast relates to of 35% in children aged 1 to 5 years.3 dists have become familiar with pe- the challenges of caring for the af- In younger children, it also is impor- diatric intramedullary nail techniques fected child. Families have reported tant to consider fractures that occur and increasingly have recognized the substantial restrictions on mobility as a result of the failure of pathologic advantages of fi xation and rapid mo- because most children are completely bone caused by minimal trauma. Al- bilization. Furthermore, early surgical dependent, requiring the use of wagons though rare, this should be suspected treatment of a child with high-energy or wheelchairs. This decrease in mo- in younger children with multiple frac- trauma, a head injury, or associated bility further affects a child’s presence tures. Several common conditions can multiple trauma may reduce compli- in school and can cause a substantial result in weakened bone and, therefore, cations and decrease the overall hos- loss of the parents’ time from work to lead to a predisposition to fracture, pital stay.4 The American Academy of care for the child.8,10 The social costs of

this treatment method have been deter- the fracture into a valgus position to mined to be greatest when the child is help counter the natural tendency of a of school age (older than 5 years) and more varus position that occurs during both parents work.1,2 healing because of the unopposed thigh adductors.8 This position also facilitates Technique hip carrying of the child, eases toilet- Two types of spica casting are common- ing, and allows school-age children to ly used. They differ based on the length attend class in a reclining wheelchair.1,2 of the cast placed on the unaffected A single-leg spica cast is positioned with limb, thereby allowing distinctive de- approximately 30° of hip and knee fl ex- grees of mobility while maintaining ion, leaving the foot positioned such Figure 1 Spica casting options. A, Unilateral hip spica cast. reduction (Figure 1). Excellent results that the child may toe-touch on the B, One and one-half hip spica cast. have been reported using both the fractured side to improve walking sta- C, Bilateral long leg hip spica cast. unilateral (single leg) hip spica cast and bility.1,2,8 Obtaining excessive traction (Courtesy of Lucile Packard Chil- dren’s Hospital, Palo Alto, CA.) the one and one-half hip spica cast.8 by grasping the calf or the foot of the Currently, there is an increasing interest fractured side or by pulling through in using the more patient-friendly, uni- a short leg cast is not recommended Complications of Spica Treatment lateral hip spica cast. A study by Epps because of the risk of peroneal nerve Shortening et al8 documented the use of a single stretching and excessive pressure on the Currently, the most commonly reported leg hip spica cast and found similar ex- calf musculature. complication of spica cast treatment is cellent results as seen with the one and After the cast has hardened, AP excessive shortening of the fracture one-half hip spica cast along with the and lateral radiographs are obtained. fragments, thereby resulting in a limb- possibility for increased mobility while Acceptable reduction parameters in- length discrepancy.9 Some shortening undergoing treatment. Therefore, the clude less than 15° of varus or valgus is acceptable but ideally should not ex- recommendation for each type of spica malalignment, less than 20° of AP ceed 2 cm. Because most children aged cast is based on the ambulatory status malalignment, less than 30° of malro- 2 to 10 years will predictably overgrow of the child, with the unilateral hip tation, and less than 2.5 cm of short- the shortened leg by 0.5 to 1 cm after spica cast used in ambulatory children ening. Children are then discharged the fracture heals, as much as 2.5 cm and the one and one-half hip spica cast after a 24-hour observation period, of shortening is acceptable in this age reserved for nonambulatory children.8 and radiographs are repeated in 7 to 10 range. After immediate spica casting, days.1,2,8 This is the ideal time for fol- the risk of losing initial reduction dou- Tips for Spica Casting low-up because the correction of small bles with each centimeter of initial In general, the positioning of the hip amounts of shortening and angulation shortening identifi ed preoperatively on and the knees and the amount of rec- may still be accomplished easily. If ex- radiographs (1 cm, 12%; 3 cm, 50%).4 ommended hip and knee fl exion vary by cessive angulation is discovered, there By using the telescope test at the physician training and preference and are two options for correction: (1) cast time of initial reduction and casting, the the position of the fracture. In most wedging for children who experience risk of shortening can be minimized. If centers, casting is performed with se- less than 15° of angulation and (2) a more than 3 cm of shortening can be dation in an operating room. When the cast change. Children with excessive demonstrated under fl uoroscopy in the fracture occurs more proximally, it is shortening may be treated by several operating room while applying gentle necessary to increase the amount of hip different strategies, which are discussed axial compression, traction or fi xation fl exion. Most physicians place children in the next subsection. rather than immediate spica casting in the semisitting position, setting the is used.1,2 In the study conducted by hips and knees at approximately 45° of Thompson et al,9 25 mm was considered fl exion. The legs are abducted approx- the upper limit of acceptable overlap of imately 30° on each side; this places fracture fragments. This group reported

are often unreliable in children. An in- to allow increased ability to examine creasing analgesic requirement may be the patient for swelling and any signs the most sensitive marker because the of neurologic dysfunction. The parents thigh and the lower leg are not avail- also should be instructed to prop up able for direct examination. Large the child in a semireclining position and Frick11 analyzed various factors to lessen the degree of elevation associ- associated with spica treatment that ated with the seated position while in might contribute to the development the spica cast. Educating parents about of compartment syndrome and the the warning signs of compartment Figure 2 Clinical photograph of subsequent possibility of permanent syndrome—such as excessive pain, skin irritation caused by the diffi - culty of providing hygienic care in a neural and muscular function loss. increased irritability, swelling, color child with a spica cast. (Courtesy of They hypothesized that the following changes, and/or problems with motor Shannon Safi er, Philadelphia, PA.) factors may contribute to compartment or sensory function—may improve syndrome: arterial spasm, increased tis- the chances of early diagnosis should sue pressures from the injury, direct compartment syndrome occur.11 Emer- a sensitivity of 80% and a specifi city pressure, elevation of the leg, venous gency fasciotomies of the lower leg to of 85%; a positive telescope test puts a stasis, and traction application tech- release all four compartments through child at approximately 20 times the risk niques during casting. Sitting position medial and lateral skin incisions is the for unsatisfactory outcome.4,9 spica casts cause forced elevation of treatment of choice for patients with This chapter’s authors prefer to the leg when a patient is supine, thus acute compartment syndromes after use fl exible intramedullary nailing to leading to possible hypoperfusion, casting. salvage shortening in acute fractures ischemia, and swelling; this cycle has whenever possible. For fractures with been hypothesized to be causative for Skin Complications excessive shortening or advanced heal- compartment syndrome in both well Another important complication re- ing, however, external fi xation that and affected legs.11 Application of lated to spica cast treatment is skin permits lengthening through the cal- pressure on the calf during the cast- damage (Figure 2). The diffi culties lus is the preferred choice; alternatively, ing procedure, either to maintain po- with hygiene, especially when a child osteoclasis and static external fi xation sition or pull traction on the affected wears a diaper, can result in the dread- can be used. Traction is rarely used in femur, has been reported as an addi- ed “poopy cast.” Skin irritation akin to the practices of this chapter’s authors. tional factor.4,11 Studies have shown diaper rash, breakdown and maceration, For fractures that heal with excessive that calf-supported positions, such as urine burns, and even cellulitis may re- shortening, an appropriately timed epi- the 90/90 spica cast, lead to increased sult from prolonged skin contact with physiodesis of the opposite distal femur pressure in all four compartments of liquid and solid waste trapped under is the best method of treatment when the leg compared with heel-supported the cast or in the padding. This chap- the limb-length discrepancy is 5 cm or positions, such as in a cast with the hip ter’s authors recommend that parents less. Gradual correction with a frame and the knee positioned at 45° or less change the child’s diaper every 2 to that permits angulation correction and of fl exion.11 3 hours regardless of whether the diaper lengthening is the treatment of choice The current recommendations to seems soiled and tuck a small diaper for shortened fractures with excessive lessen the risk of this complication in- under the cast edges while covering deformity. clude (1) applying a long leg cast fi rst the entire perineum with a second and then applying traction or (2) apply- larger diaper. Increased wetness and/ Compartment Syndrome ing the upper part of the cast fi rst while or foul odor require inspection and Another important yet rare complica- holding the foot of the fractured leg cast trimming or a complete change of tion of spica casting is compartment without applying traction. This avoids cast. Although expensive, a waterproof, syndrome in the affected lower leg. The pressure in the calf region. Another op- breathable liner may help to decrease classic signs of compartment syndrome tion is to leave the foot out of the cast skin problems.1,2,4

Flexible Intramedullary fashion for more distal fractures or a ret- avoid this complication, the nail should Nailing rograde fashion for diaphyseal and more be trimmed short enough to allow it Flexible intramedullary nailing—a proximal fractures.6 A disadvantage of to lie in apposition with the distal fl are technique fi rst used in Nancy, France, proximal entry relates to the lack of safe medially and just proximal to the physis in the early 1970s—has become an medial and lateral starting points, which laterally, deep to the iliotibial band. This increasingly popular method of fi xa- can result in unbalanced and asymmet- chapter’s authors prefer to trim the nail tion for pediatric femoral fractures. Its ric implants.4 just before its fi nal seating, with fi nal ideal application is in skeletally imma- Most fractures can be treated with positioning achieved by a hollow tamp. ture children aged 5 to 11 years who nails advanced in a retrograde fashion. Alternatively, the nail may be pulled have transverse fractures in the middle To begin, medial and lateral starting back from its fi nal position, trimmed, 60% of the femoral diaphysis.1,2,4,6 Poor drill holes are made 2.5 cm proximal and then advanced again. Although outcomes have been reported as fi ve to the distal femoral physis at approx- many patients will be symptomatic times more likely in patients who weigh imately a 10° angle to the cortex. The while the nails are in place, most will more than 108.5 lb and four times more fi rst nail is advanced to the fracture site, experience relief and regain full knee likely in patients older than 11 years.1,2 the fracture is reduced, and the nail is motion after hardware removal, which This method of fi xation functions as then driven across it. The second nail is is typically done 9 to 12 months after an internal splint that holds length and then advanced across the fracture site. the fracture occurred and when radio- alignment but permits enough motion Nail rotation and fracture manipulation graphs document complete healing. at the fracture site to generate suffi cient make crossing the site easier. Both nails callus.4 are then advanced proximally until they Mismatched Nails and Loss of Reduction This technique offers relatively easy reach their fi nal resting positions, with Loss of reduction is typically caused by pin insertion and removal, satisfactory the nail that entered the lateral cortex a combination of two important factors: fi xation, and earlier mobilization and resting just distal to the trochanteric improper implant usage and improper return of function compared with apophysis and the medial nail pointing indications for fl exible nails. The ideal nonsurgical techniques. There also to the lesser trochanter. The nails are titanium nail construct is two identi- are smaller scars compared with other then cut distally. A small portion of the cal nails, each with a diameter that fi lls surgical treatments, such as external nail, less than 1 cm should be allowed approximately 40% of the canal, con- fi xation and plating.1,2,6 Furthermore, to remain outside the cortex to facilitate toured such that the maximal spread of this technique avoids the risks of fem- removal and lessen irritation on the soft the implants occurs at the fracture site. oral head osteonecrosis and premature tissues.10,13 The largest possible nail size that per- greater trochanteric epiphysiodesis mits two nails of similar size to fi t into associated with rigid intramedullary de- Complications of Flexible Nails the medullary canal should be chosen. vices and spares injury to the physes.12 Soft-Tissue Irritation Around the Knee The correct nail size can be selected Soft-tissue irritation at the insertion site by preoperatively measuring the canal Technique of Nail Insertion is the most common complication of with radiography or intraoperatively The French pioneers in fl exible intra- the procedure. This may be from nail placing the nail over the femoral ca- medullary nailing stressed the critical contact with the quadriceps medially nal using fl uoroscopy. Using nails that importance of proper technique, includ- or, more commonly, the iliotibial band are too small or mismatched increases ing prebending the nails so that the apex laterally. Patients with nail ends in ex- the rate of complications.1,2,6,13 The use of the bend is located at the fracture site cess of 10 mm or more report pain or of mismatched nails produces unequal to produce a spring effect.1,2,13 By posi- irritation at the knee 4.5 times more force loads that can result in angulation, tioning the nails in this manner, the im- often than those with shorter lengths loss of reduction, or radiographic mal- plants balance one another to prevent of nail protrusion. For some patients, union. It has been reported that loss of bending, control rotation, and add to the pain or irritation at the nail insertion reduction or radiographic malunion was rigidity of fracture fi xation. Nail inser- sites may necessitate reoperation to ad- 19 times more likely when mismatched tion can take place in either an antegrade vance, trim, or remove nails early.6 To nails were used.6

Figure 3 A, Immediate postoperative radiograph of a transverse femoral fracture in a 12-year-old girl treated with ﬂ exible nail ﬁ xation. B, Radiograph taken at the 1-week follow-up shows 15° of angulation in varus. C, Radiograph of the fracture after the cast was wedged in the clinic. D, Radiograph of the fracture at the 3-month follow-up.

Inadequate Nail Size and Loss of Reduction these fractures being four times more after surgery. However, if fracture sta- The use of nails that are too small or too likely to result in a loss of reduction bility is unclear, alternative methods fl exible can lead to loss of reduction be- than those without comminution.6 It of fi xation that are better suited for cause of the increased stress on the im- has been advised that fractures with unstable fracture patterns rather than plants from an excessively large patient greater than 25% cortical comminu- fl exible nails should be used, includ- or an unstable fracture pattern. Nails tion be closely monitored to detect early ing submuscular plating and external that are 4.0 mm in diameter are best loss of reduction and may even benefi t fi xation, both of which may be used to for children weighing less than approx- from additional external immobiliza- successfully treat unstable diaphyseal imately 110 lb and are not recommend- tion or alternative methods of fi xation.14 fracture patterns (Figure 3). ed for larger children. Flexible stainless In another study addressing unstable steel nails are an alternative to titanium fracture patterns, the authors concluded Distal Femoral nails and have recently gained popu- that stainless steel nails might have an Physeal Fractures larity because they are more rigid than advantage over their titanium counter- Distal femoral physeal fractures in chil- equivalently sized titanium nails and parts in maintaining reduction.12 dren, most commonly Salter-Harris may afford added stability for heavier type II fractures, are relatively rare in- patients. However, titanium nails allow Tips to Avoid Complications juries and account for fewer than 2% more micromotion and therefore stim- To avoid loss of reduction, this chap- of all physeal injuries.1,2,15,16 The most ulate more rapid healing. ter’s authors always use two titanium common mechanism of injury is a varus nails of the same size that together fi ll or valgus stress positioned across the Unstable Fracture Patterns 80% of the canal. Stainless steel nails knee joint, such as from sports activities In addition to patient size, unstable frac- are reserved for patients weighing more or motor vehicle crashes. In skeletally ture patterns present another challenge than 110 lb or a rigid locked lateral entry mature patients, this stress typically because of the added stress placed on nail is used in place of fl exible nails. If causes ligament disruption. However, the implants. In a study using titanium unstable fracture patterns are treated in an immature knee, tensile forces are elastic nails in pediatric femoral frac- with fl exible nails, this chapter’s authors transmitted through the ligaments to tures, comminuted fractures stabilized will often immobilize the limb in a uni- the physis, which can lead to disrup- with titanium elastic nails were more lateral spica cast for 3 to 4 weeks or use tion of the periosteum, with a result- likely to experience complications, with a knee-ankle-foot orthosis temporarily ing fracture plane through the distal

Figure 4 AP (A) and lateral (B) radiographs of a Salter-Harris type II fracture of the distal femoral physis in an 8-year- old girl. AP (C) and lateral (D) views of the fracture after closed reduction and percutaneous pinning in the operating room. femoral physis.1,2 Anterior displacement type I fractures. This chapter’s authors alignment with stable fi xation improves of Salter-Harris types I and II fractures bury the Kirschner wires beneath the the chances of a good outcome. For may be associated with popliteal artery skin and then return to the operating minimally displaced fractures, percu- injuries, whereas severely displaced var- room in 4 to 6 weeks to remove them. taneous placement of smooth wires or us deformities may be associated with Alternatively, the wires may be cut out- cannulated screws is one option and is peroneal nerve palsies. side the skin and removed in the clin- preferred by this chapter’s authors when ic at 3 to 4 weeks. If the metaphyseal possible. Open reduction is necessary Treatment fragment is large, one or two 4.5- to for fractures not amenable to closed re- Casting 7.3-mm cannulated screws with wash- duction. Medial condylar types III and Most nondisplaced fractures are treated ers are placed transversely through the IV fractures are more common than with a long leg cast and no weight bear- metaphyseal fragment into the bone lateral condylar types III and IV frac- ing on crutches for 4 weeks followed by of the femoral shaft while holding the tures. An anteromedial or an antero- progressive weight bearing in a cast or reduction. Ideally, the threads of the lateral approach to the knee is used to a hinged knee brace for an additional screws completely cross the fracture site perform open reduction, based on the 4 weeks. All displaced fractures should and achieve compression. After the pro- location of the fracture1,2 (Figure 5). be ideally treated with reduction, either cedure has been completed, a long leg Screw placement can, at times, be closed or open, and fi xation. cast is then applied for a period of 4 to challenging. One study highly recom- 6 weeks to aid in stabilization. mended obtaining a CT scan preop- Surgical Treatment eratively to help plan the placement Salter-Harris Type I and II Fractures Salter-Harris Types III and IV Fractures of percutaneous cannulated screws.17 Displaced Salter-Harris type I frac- Nearly all Salter-Harris types III and One or two cannulated screws placed tures require reduction under anesthe- IV fractures, regardless of whether they through the epiphysis and parallel to the sia. After manual reduction has been are displaced, are best treated with fi x- physis, avoiding the notch, is suffi cient achieved, the fracture is secured with ation because of their unstable nature fi xation for most fractures. Screw sizes crossed, percutaneously placed, smooth and the tendency to displace in a cast vary from 4.5 mm to 7.3 mm, depend- Kirschner wires.17 For Salter-Harris alone during the fi rst several weeks after ing on the size of the patient. To ensure type II fractures (Figure 4) with a small injury if fi xation is not used.17 In addi- proper placement of the implant, it is Thurston-Holland fragment, treatment tion, these fractures are intra-articular important to rotate the leg under fl u- is done similarly as for Salter-Harris as well as physeal, and, hence, anatomic oroscopy to visualize the screw at its

physis is another etiology. Radiographs can be examined for the appearance of a Park-Harris line, which is a fi ne, sclerotic line within the metaphysis that develops parallel to and proximal to the physis. If normal growth has resumed after the fracture, this line grows away from the physis in a sym- metric and parallel fashion. However, if an oblique line appears, this indicates asymmetric growth and warrants further follow-up.1,2 MRI also is useful for the early detection of bone bridge formation; MRI can detect growth disturbance as early as 2 months after the 1,2,15 Figure 5 A, AP radiograph of a Salter-Harris type III fracture of the distal initial injury. femur in an 11-year-old boy. B, CT scan of the fracture. Prevention longest length. By doing so, the surgeon to 2007 that included 564 fractures, Growth arrest may be seen after any can verify that the screw is not sitting 52% of the fractures resulted in growth fracture type regardless of displacement outside the bone or potentially in soft disturbance.18 Overall, high risks for but is most common after displaced tissue. After fi xation, a long leg cast growth arrest include displaced frac- fractures. The risk can be diminished is applied. Most fractures heal within tures, nonanatomic reduction, and open in patients with displaced fractures by 6 to 8 weeks of injury. Knee stiffness fractures. achieving anatomic reduction with as after fracture healing can be reduced little surgery as possible and maintain- by encouraging knee motion as soon Consequences of Growth Arrest ing the reduction with stable fi xation as fracture healing is evident clinically The consequences of growth arrest are that does not harm the physis. In a and radiographically. Return to activi- most severe in children younger than rabbit model, transphyseal smooth ties can be expected 3 to 4 months af- 10 to 12 years because of their rapid wires that disrupt less than 7% of the ter the fracture. All skeletally immature growth and advancing skeletal matu- cross-sectional area of the distal femo- patients who sustain these fractures ration. The distal femoral physis grows ral physis do not cause growth distur- should be followed radiographically at about 9 mm per year in a healthy child bance.16 In contrast, transphyseal screws 4- to 6-month intervals until skeletal and accounts for nearly 40% of the or plates that cross the physis should maturity to facilitate early diagnosis of overall growth of the lower extremity. be avoided because these implants will growth arrest. Because of this, complete growth arrest inhibit physeal growth. of the distal femur can produce a sub- Complications stantial difference in limb length, and Surgical Options Growth Arrest an incomplete arrest can produce sig- If growth arrest is identifi ed early in The most common and serious com- nifi cant angular deformity of the knee.17 a child with at least 2 years of growth plication of fractures of the distal remaining and MRI mapping of the femoral physis is growth disturbance Diagnosis physeal bar shows that less than 50% leading to angular deformity and/or Growth arrest is typically the result of of the growth plate is bridged, physeal shortening.1,2 These fractures have a bony bridge formation resulting from bar resection and interposition with fat reported incidence of 30% to 70% of either direct physeal trauma to the rest- is an option. Completion of the partial growth arrest.15,17 In one meta-analysis ing chondrocytes or a nonanatomic re- arrest and epiphysiodesis of the contra- of the published literature from 1950 duction. Screw fi xation that crosses the lateral distal femur also may be done

when the physeal bar has been identi- ﬁ ed soon after fracture healing and no signiﬁ cant limb-length discrepancy or angulation has occurred. Appropriately timed epiphysiodeses, osteotomies, and limb-lengthening procedures done sep- arately or combined are other options used to treat growth arrest depending on the age of the child, the expected limb-length discrepancy, and the degree of angulation (Figure 6).

Vascular Injur y Figure 6 A, AP radiograph taken in the emergency department of a Vascular injury can occur in association Salter-Harris type II fracture of the distal femur in a 13-year-old boy. B, AP with distal femoral fractures, especially radiograph taken 6 months after treatment shows formation of a physeal bar and angular deformity. C, AP view of the fracture after a corrective osteotomy if the epiphysis is displaced anterior- was performed. ly with severe apex posterior angulation because the popliteal artery may be stretched or lacerated by the distal Improper casting of a swollen extrem- II fractures of the distal femur.17 Lim- end of the femoral metaphysis. In the ity in greater than 90° of fl exion after itation of knee motion may be caused emergency department, it is critical that fracture reduction or immobilization by intra-articular adhesions, capsular (1) pulses are palpated and (2) capil- of a nondisplaced fracture in this posi- contracture, or muscular contracture. lary refi ll is assessed to determine if an tion can compromise the popliteal ves- This should be treated with an aggres- associated vascular injury has occurred. sel and interfere with distal circulation, sive physical therapy program that in- If the diagnosis of arterial injury is not potentially leading to compartment cludes both active and active assisted clear, measuring the ankle-brachial syndrome. Other etiologies of com- range-of-motion exercises. For patients index has been shown to be reliable partment syndrome include associated with persistent knee stiffness in whom for detecting a possible arterial injury lower leg trauma, such as a crush in- conservative treatment has failed, MRI compared with assessing pulses by ei- jury or a tibia fracture (fl oating knee is indicated to rule out intra-articular ther palpation or Doppler signal assess- variant), and prolonged limb ischemia processes, such as meniscal tears or ment.17 If a patient has poor distal limb from an arterial injury. If severe swell- chondral lesions that may be contribut- perfusion or none at all, the best option ing is noted after fracture fi xation, the ing to the diffi culty with rehabilitation. is to proceed to the operating room limb should be splinted in 20° to 30° Arthroscopic-assisted manipulation un- emergently for reduction and fracture of fl exion and casted when the swell- der anesthesia and surgical release of fi xation. If perfusion to the limb is ing has subsided. To reduce the risk of contractures are rarely necessary but are not restored, open exploration in the compartment syndrome after a fl oat- options for patients with persistent loss popliteal space is indicated. A lower leg ing knee injury, stable fi xation of both of knee motion.1,2 fasciotomy is performed before leaving fractures and postoperative splinting the operating room if the limb ischemia is best. Compartment syndrome of Summary time is longer than 4 to 6 hours. the lower leg is treated with four- Femoral shaft fractures and distal compartment fasciotomies. femoral physeal fractures are common Compartment Syndrome injuries in pediatric patients and fre- Compartment syndrome of the lower Knee Stiffness quently require stabilization and/or leg has been reported to occur in 1.3% Long-term loss of knee range of mo- fi xation. Complications are common of Salter-Harris fractures, and peroneal tion has been reported in as many as in both of these types of injuries but nerve palsy has been observed in 7.3%.17 25% of patients with Salter-Harris type can be minimized by understanding

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