Fig. 21.1
Garden classification
No matter how displaced the fracture, it is worth an osteosynthesis at these ages. The reduction, if needed, can be performed in an open or closed approach. Leadbetter has described the maneuver for closed reduction. It should be tried only once, in the operating room. It is performed under traction and by applying a sequence of flexion-adduction-extension-internal rotation. Open reduction is accomplished through anterior approach to preserve the vessels.
The most recommended type of fixation is compression screws (Fig. 21.2).
Fig. 21.2
Neck fracture from a fall during match in a 37-year-old professional goalkeeper. Treated with cannulated screws (Images from preop and 9-month post-op)
It has been demonstrated [18, 19] that they offer a lesser risk of failure when technique is well observed. Being intracapsular fractures, there is a great risk of pseudarthrosis. That can only be avoided with good anatomical or valgus reduction and stable compressive fixation. The screws need to be placed without any risk of vascularization damage by rotation of the femoral head and ideally in a number of 3. Varus fixation is related to postoperative displacement. Observing good technique is of utmost importance, for resistance to cyclic shearing forces. Entry point should be at or under the lesser trochanter level. Screws should stay 5 mm from chondral surface but should enter the denser subchondral bone. They should be placed near the cortical in the neck for increased stability.
The risk of AVN is 3–20%. Capsular decompression is to be considered.
21.2.4.3 Pertrochanteric Fractures
The most frequent are intertrochanteric, but there can be fractures affecting only one trochanter (Fig. 21.3).
Fig. 21.3
Greater trochanter fracture from collision and forced abduction against resistance in a 27-year-old professional player (Images from preop and post-op)
These extracapsular fractures do not put the femoral head vessels at risk and usually have a low risk of pseudarthrosis because they involve mostly cancellous bone. There are many classification systems, but the most important aspect is to determine if a fracture is stable or not. Evans classification describes progressive instability of intertrochanteric fractures (Fig. 21.4).
Fig. 21.4
Evans transtrochanteric fracture classification
The usual types of fixation are sliding screw plates or nails (Fig. 21.5). Both have good results. The former have the need for more soft tissue dissection and are related to more blood loss during surgery but allow for intraoperative reduction of displaced fractures. Nails are placed closer to the mechanical axis and have smaller bending moments; they are associated to lesser blood loss during surgery, but they need a good closed reduction on the fracture table to ensure a good result.
Fig. 21.5
Transtrochanteric fracture fixation with dynamic screw plate and nail
21.2.4.4 Subtrochanteric Fractures
Subtrochanteric fractures are considered difficult to treat. The iliopsoas exerts a strong force that displaces the fracture in the three planes. This makes it more challenging to reduce and realign. The treatment often requires the combination of transtrochanteric with shaft fixation methods.
21.2.4.5 Shaft Fractures
Shaft fractures are the most frequent femur fractures in players, especially under the age of 20. They are associated to significant blood loss, and they need immediate stabilization to avoid serious complications such as shock, fat embolism, and eventually death. Thomas splints, or other traction splints, are all temporary stabilization devices that can be used before definitive treatment. External fixation is recommended for open fractures or in the case of a delay of internal fixation surgery, whatever the reason.
There are three main types of fractures: spiral, oblique, and transverse. They can present with variable degrees of comminution.
Being extra-articular fractures, they do not need anatomical reduction, just alignment and rotational deformity restoration. They will benefit from stable relative fixation, which allows for micromotion, such as nailing. This is probably the best choice of treatment (Fig. 21.6).
Fig. 21.6
Shaft fracture in a 32-year-old female professional resulting from direct blunt trauma during match (Images of preop and post-op)
Using plates is an alternative, but they imply more tissue aggression. They should be placed as bridge plates to avoid losing the hematoma and the biologic local response to bone fracture. If used, they should be used percutaneously as an ideal procedure.
Open fractures need a different approach. The need for early stabilization remains the same. Surgical debridement is mandatory. Reaming of the medullary canal is not recommended, and internal fixation may need delaying for better local and skin conditions.
21.2.4.6 Supracondylar, Intercondylar, and Unicondylar Fractures
These are discussed in the chapter related to knee fractures.
21.2.5 Rehabilitation
Physical therapy is focused on early mobilization and gait resumption. A program will begin in immediate postoperative period.
In the first 4 weeks, many modalities can be used. Faradic stimulation will help in pain management, swelling control, and muscle reeducation. Gentle passive mobilization, active isodynamic, and isometric exercises of the muscles around the hip, knee, and ankle can begin: stretching of the hamstrings, gastrocnemius, and soleus; strengthening of the quadriceps; straight leg raise in four planes; ankle dorsiflexion; and plantar flexion, eversion, and inversion.
In the second phase (4–8 weeks), there will be progress in strengthening exercises, balance, and proprioceptive and gait retaining activities. For this, the criteria for progression are minimal effusion, 50% weight bearing, and fair grade strength of hip abductors and quadriceps. Fitting with stationary bicycle and pool therapy can begin.
After 8 weeks, progressing is depending on full weight bearing without assistive devices, no effusion, and strength of the hip abductors and quadriceps. Strengthening exercises gradually increase in effort and resistance. The same happens for balance, proprioception, and gait training activities. Fitness condition exercises gradually progress to regain pre-injury state. This can take up to 18 weeks.
21.3 Fractures in Children
Most of sport-related lesions in children are minor and self-limiting. So, children and youth sports are safe. But fractures may occur. Femur fractures are the least seen among others. This is related to the amount of energy necessary to cause fracture. It is, after all, the strongest of bones.
Risk factors are training in poor environment, improper footwear, and improperly supervised high-resistance training [20]. Although boys are predominant in football, it is the leading sport for injuries in girls. Amenorrheic anorectic females are at risk due to reduced bone density. To help reduce the risk of injury, cross-training and gradual schedule changes are good practices.
21.3.1 Children’s Bone
There are many differences between children and adult bone healing. Because of a more biologically active periosteum, bone healing is faster. Callus forms rapidly and there is a great potential for remodeling. Deformities resulting from malunion will often disappear with remodeling, excepting for rotational deformity. That means anatomic reduction is not necessary, and other forms of treatment are possible.
There are problems exclusive to children, such as overgrowth, causing limb length discrepancy. Deformities resulting from fractures at ossification centers or growth plates will progress with age. In growth plate trauma, some sort of growth disturbance might be expected, such as limb length inequality or angular deformity.
Salter and Harris have proposed a classification system that relates patterns of fracture with the risk of complications to the growth (Fig. 21.7).
Fig. 21.7
Salter-Harris classification
Treatment can be conducted conservatively in many cases. When surgery is needed, it must be modified to avoid injury to ossification centers and growth plates.
21.3.2 Fractures of the Diaphysis
Femoral shaft fractures account for 1–2% of all pediatric fractures.
Because of the great remodeling potential children have, there is a place for conservative treatment. As long as there is no rotational deformity, the bone will heal well in the vast majority of the cases. Deformity resulting from malunion of displaced ends and limb length discrepancy will recover by remodeling. But that potential for full recovery decreases with age, and surgery will become necessary for comfort, to help faster mobility, and to avoid bad outcome.
Overgrowth after a fracture, causing length discrepancy, is a rare complication.
21.3.3 Fractures Through the Growth Plates, the Epiphysis, and the Apophysis
Growth plate injury can cause permanent and developing deformities. If growth stops at an entire growth plate, there will be a shortened limb. It will not grow as fast or as much as the contralateral. Or it may not grow at all. If the growth disturbance only affects a part of the growth plate, there will be an angular deformity. The affected part will be in the concave side of the deformity.
21.3.3.1 Traumatic Physeal Fracture of the Femoral Head
The femoral head represents less than 1% of all pediatric fractures.
The femoral head contributes for 30% of the length of the femur and 13% of the limb. Damage to the head causes shortening as well as articular damage.
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