(a, b) A proximal femoral diaphyseal fracture treated by closed reduction and immediate spica casting healed in adequate alignment, anticipating future remodeling. (c) Child walking in single-leg “walking spica” cast. The patient is wearing two diapers, one totally inside the cast
High-energy, comminuted, and short oblique fractures are often length unstable and require skeletal traction for 10–21 days before application of a spica. Proximal shaft fractures must be casted in 70–90° hip flexion as the proximal fragment is pulled into flexion by the psoas muscle. If traction is used, 90–90° traction is required (Figs. 13.16 and 28.2). Midshaft fractures can be casted in the midrange of hip flexion. The authors’ preference is to leave the foot out of the cast.
Fig. 28.2
90–90 traction is considered for 14–21 days in length-unstable fractures, aiming for 1–1.5 cm of shortening in children between 3 and 8 years of age
Without portable imaging when the patient is treated in traction, limb lengths must be evaluated by clinical examination, taking care to avoid distraction. Ideally the affected limb will be shortened 1–1.5 cm to account for the expected overgrowth. When the fracture can be gently squeezed without pain, healing is sufficient for casting.
Six Years Through Skeletal Maturity
Controversy surrounds the optimal management of patients from 6 years through skeletal maturity, and the best approach depends on the availability of a suitable environment for open surgery, portable radiographs or an image intensifier, and implants. Children in austere environments are often smaller with less muscle mass and bulk than their western chronological counterparts, skewing treatments to non-operative choices normally recommended for chronologically younger patients. Traction is an acceptable choice for any age. Proximal shaft fractures require 90–90° traction, and midshaft fractures can be treated in balanced skeletal traction with the hip in less flexion. Distal shaft fractures are more difficult to manage in traction, as the pull of the gastrocnemius on the distal fragment results in posterior sag. In addition to a longitudinal traction vector through the proximal tibia, with care to avoid the physis, a second traction pin is needed in the distal fragment with the force vector directed anteriorly to counter the pull of the gastrocnemius (see Fig. 13.22).
Some distal shaft fractures may be amenable to fixation with crossed Kirschner wires or Steinmann pins, but the two wires should not cross the fracture at the same point as stability will be inadequate. Implants placed from distal to proximal may be intra-articular, risking septic arthritis. To avoid this one can start fixation proximally though this must pass through thicker soft tissues and care must be taken to avoid the femoral artery for the medial fixation. These implants can usually be removed in the clinic setting.
The majority of length-stable fractures—transverse and mid-diaphyseal, in patients less than 50 kg—can be treated with an intramedullary implant. While flexible nails are unavailable in many settings (Fig. 28.3), a Rush rod can be used, recognizing that a spica cast is often required for rotational stability. An open reduction is usually required in the absence of an image intensifier, especially if the patient presents after a few days. A single Rush rod can be inserted through the tip of the greater trochanter and advanced across the fracture. Alternatively, two pre-contoured rods can be inserted from the distal metaphysis and advanced proximally. When flexible nails are used to manage distal diaphyseal or meta-diaphyseal fractures, consider inserting the devices proximally, with lateral entry in the trochanteric region above the lesser trochanter, with one nail pre-contoured into a “C” shape and the other contoured and rotated into an “S” shape. Avoid piriformis fossa entry in any proximal nail, flexible or rigid, in the skeletally immature due to the risk of avascular necrosis. Flexible nails may also be used to manage proximal diaphyseal fractures, and they are both inserted in the distal metaphysis with the medial nail extended up into the femoral neck and the lateral nail up to the tip of the greater trochanter. Care must be taken to avoid perforation proximally, and images in different degrees of rotation may help avoid this situation.
Fig. 28.3
Flexible nailing for a diaphyseal femur fracture
External fixators can be viewed as portable traction and are especially beneficial for open fractures needing wound care. Use two half pins per fragment, and place them at least 3–4 cm from the fracture (Fig. 28.4). The resulting semirigid fixation allows micromotion, which stimulates callus. When more rigidity is needed, external fixation principles for adult fractures can be used based on individual experience and judgment. Disadvantages of external fixation include the risk of refracture, especially in transverse fractures; pin tract infection or sepsis if adequate hygiene cannot be provided when the patient returns home; and the need for a second procedure to remove the fixator. The risk of infection due to contaminated pin sites is likely greater when a fixator is converted to an intramedullary device. Open reduction and plating is an option with an increased risk of infection compared with other treatments. This approach may be best suited for distal meta-diaphyseal fractures, and care must be taken to place the distal end of the implant more than 2 centimeters from the physis to reduce the risk of a progressive valgus deformity from physeal growth disturbance.
Fig. 28.4
(a) This length-unstable diaphyseal fracture was treated by (b) external fixation and (c) healed in satisfactory alignment
Tibia and Fibula Fractures
The majority of tibial shaft fractures, with or without fibular fracture, are amenable to closed management. These fractures are at risk for valgus angulation due to the pull of the anterior compartment muscles, and the remodeling potential is more limited for fractures with valgus and/or apex posterior angulation. Shortening up to 1 cm is acceptable, recognizing that the average overgrowth is 5 mm in children between 2 and 10 years. Fifty percent apposition of the fragments is acceptable (Fig. 28.5). Unstable fractures requiring reduction are commonly managed in a long leg cast for the first few weeks, with transition to a short leg, weight-bearing cast once early callus has formed. Weekly radiographs are required for 2–3 weeks or until callus is present. At any time in the early treatment, cast wedging may be necessary to maintain alignment (see Chap. 13).
Fig. 28.5
This proximal tibial fracture was treated closed after manipulation to correct the valgus and healed in acceptable alignment although translation was >50%. The patient was asymptomatic. (a) Initial X-ray. (b) After reduction and 6 weeks casting
The risk of compartment syndrome is increased for direct, blunt trauma, as well as high energy injuries. In austere settings compartment syndrome must be diagnosed clinically, and the index of suspicion is heightened by agitation and increasing requirements for pain medicine.
Indications for operative management include open injuries, inability to achieve or maintain a closed reduction, neurovascular injury, compartment syndrome, and floating knee injuries. Treatment options include traction, closed reduction, and percutaneous fixation with a K-wire or Steinmann pin in proximal or distal metaphyseal fractures (Fig. 28.6), external fixation, intramedullary fixation, and open reduction and plating. Traction is rarely required when an external fixator is available but can be delivered via a calcaneal or distal tibial pin. External fixation is ideal for open fractures requiring wound management, recognizing that the time to union is increased, and complications are frequent especially following open fractures. The fixator should be either dynamized or removed as soon as soft tissue healing allows.
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