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Osteosynthesis in a 10 year old boy with Fracture neck of Femur, Infected Nonunion with Implants In-situ, Neck Resorption and Avascular Necrosis -A case report.

Vol 1 | Issue 1 | July-Sep 2015 | page:48-50 | EG Mohan Kumar, GM Yathish Kumar. Authors : EG Mohan Kumar[1], GM Yathish Kumar[1]. [1] Department Of Orthopedic Surgery, KIMS Al Shifa Hospital, Perintalmanna, Kerala, India. Address of Correspondence Dr. EG Mohan Kumar HOD Department Of Orthopedic Surgery, KIMS Al Shifa Hospital, Perintalmanna, Kerala- 679322 India. […]

Open reductions of Paediatric Supracondylar Humerus Fractures- When, How and, Risks

Vol 1 | Issue 1 | July-Sep 2015 | page:16-18 | Ashish Ranade, Gauri Oka. Authors : Ashish Ranade[1], Gauri Oka[1]. [1] Dept. of Orthopaedics, Deenanath Mangeshkar Hospital, Pune 411004. Address of Correspondence Dr Ashish Ranade Dept. of Orthopaedics, Deenanath Mangeshkar Hospital, Pune 411004. Email address:ashishranade@yahoo.com Abstract Supracondylar humerus fracture is one of the commonest fractures in […]

Osteosynthesis in a 10 year old boy with Fracture neck of Femur, Infected Nonunion with Implants In-situ, Neck Resorption and Avascular Necrosis -A case report.

Open reductions of Paediatric Supracondylar Humerus Fractures- When, How and, Risks

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Osteosynthesis in a 10 year old boy with Fracture neck of Femur, Infected Nonunion with Implants In-situ, Neck Resorption and Avascular Necrosis -A case report.

Vol 1 | Issue 1 | July-Sep 2015 | page:48-50 | EG Mohan Kumar, GM Yathish Kumar.

Authors : EG Mohan Kumar[1], GM Yathish Kumar[1].

[1] Department Of Orthopedic Surgery, KIMS Al Shifa Hospital, Perintalmanna, Kerala, India.

Address of Correspondence
Dr. EG Mohan Kumar
HOD Department Of Orthopedic Surgery, KIMS Al Shifa Hospital,
Perintalmanna, Kerala- 679322 India.
Email- orthomohan@rediffmail.com.

Abstract

Background: Non union fracture femoral neck is one of the common complication of intra capsular fracture neck of femur in children as well as in adults and it is the most challenging problem to treat if femoral head salvage is attempted. Other common complication is avascular necrosis (AVN) of the femoral head with most reported incidences being <15% (range 0% to 67%), which is similar to the complication rate with non-neglected femoral neck fractures. We are reporting a case of 10 year old boy who elsewhere underwent closed reduction and internal fixation with canulated cancellous screw for Delbert type III fracture neck of femur, which subsequently got infected with a draining sinus, non union and AVN of femoral head with complete absorption of the neck in 4 months time. We received the patient at that stage. He was managed by two stage surgery. Initially the implants were removed the screw tracks were curetted out and filled with antibiotic sponge. After the infection was eradicated osteosynthesis and neck reconstruction was done using fibular strut and cancellous grafts through modified Watson Jones approach and anterior capsulotomy . We avoided metal implants for fear of infection and so also a subtrochenteric osteotomy which require fixation. A hip spica cast was given for 6 weeks. The neck length was restored, vascularity restored and fracture united with an excellently functioning hip.
Keywords: Femur neck fracture, infection, osteosysnthesis.

Introduction
Fractures of the femoral neck in children are not common[1]. They represent fewer than 1% of all the paediatric fractures2. However, complications accompanying these fractures are frequent—specifically avascular necrosis, non union and early closure of the proximal physis of the femur—resulting in decrease of neck length and coxa vara. The incidence of non union varies from 7 to 10%, depending on the location of the fracture in the neck of femur[2,3,4]. Delbet was the first to describe the fractures of the femoral neck. He published the first classification in the French literature. Since then, Colonna[5] has quoted the Delbet classification, which is still accepted in all the literature regarding this subject, and Ratliff[6] has described the evaluation criteria of the results, based on the presence of pain, joint mobility and the child’s capacity to maintain a daily activity. Most of the articles in the literature support bone grafting and a valgus osteotomy with some sort of fixation[7]. Only few cases reported with non union neck of femur treated by fibular strut graft alone without fixation and osteotomy. We feel that our case was unique due to presence of infection which makes the situation complicated. Here, we report a case of paediatric femoral neck fracture which went in for all described complications like AVN, non union, infection and neck resorption which was managed successfully by staged surgery. In the first stage eradication of infection and in second stage osteosynthesis and neck length restoration was attempted.

Case Presentation
A 10 year old boy sustained fracture neck of right femur following fall from tree 4 months back(Fig.1) and was initially treated elsewhere by closed reduction and Canulated Cancellous Screw and K wire fixation(Fig.2), but osteosythesis was failed due to infection and poor fixation. He presented to us with non union, neck resorption, avascular necrosis of head of femur and infection with implants insitu(Fig.3). His WBC count(13000cells/cumm), ESR(40mmhg/hour) and CRP(110) were elevated. X-Ray showed loosening of implants with surrounding osteolysis and he was managed in two stages. Initially implants were removed, debridement was done, screw tracks were curetted out and antibiotic sponge was kept inside the tracks and was put on antibiotics(Fig.4). Once the infection got settled when CRP became normal after two months he was taken up for second stage surgery. He was treated by autologous fibular strut grafting and cancellous graft packing through Modified Watson Jones approach. Intra-operatively he was put on traction table, reduction and alignment was checked under C-ARM guidance(Fig.5), we could restore the length of neck with fibula graft under C-ARM guidance and cancellous gaft harvested from iliac crest was filled around fibula graft bridging fracture site through anterior capsulotomy(Fig.6,7). Patient was immobilized in hip spica cast for 6 weeks(Fig.8), POP was removed and X-ray taken .Gradually hip and knee were mobilized. He was reviewed every month with radiograph which showed good union of fracture and vascularity of the head of femur spontaneously improved(Fig.9,10). Made partial weight bearing with the support of walker at 3 months post op and gradually increased weight bearing. Fracture consolidated by 6 months. At present his fracture is completely united, vascularity of head of femur regained(Fig.10). He has got 1cm shortening of limb and patient is back to school walking without support without any pain. Since the proximal physis is fused he may develop an increase in the present limb length discrepancy which we plan to correct later.

Discussion
Fracture neck of femur in children is a rare injury and can lead to many complications. Nonunion and AVN are very common complication which is nearly equal in neglected and treated cases of fracture neck of femur[8].Infection further adds to challenge in treating these cases. We got chance to treat such a patient with failed osteosynthesis neck of femur with all known complication like infection, pseudoarthrosis, avascular necrosis and neck resorption. Investigation of nonunion of neck of femur should include TC,DC,ESR and CRP to rule out infection especially in failed osteosynthesis, MRI may be required if x-ray features are not conclusive of vascular status of head of femur. In the literature there are few articles about treating this challenging problem. All are supporting valgus osteotomy some sort of fixation, few are supporting fibular grafting and cancellous screw fixation[4,9], but all concerning situations without infection. We planned to tackle the infection first and go for osteosynthesis with bone grafting alone without osteotomy or use of any hardware for fixation, in view of the subsided infection. Fibular strut graft gave a very good structural support also helped us to maintain the neck length and cancellous graft helped in fracture healing and to some extent improve vascularity of femoral head which made him walk again. Patient may have LLD which is to be addressed at skeletal maturity.

Clinical Relevance
Although fracture neck of femur in children is a rare injury, complications are very common and challenging to treat. Thorough investigations are must before treating these complications of neck of femur fracture. Infection must be ruled out in failed osteosynthesis. In selected cases fibula strut grafting and cancellous grafting allow neck reconstruction and fracture healing without fixation in children. Initial immobilization with spica cast and close follow up and monitoring during post operative period is essential to achieve the goal.

References

1. Miller WE (1973) Fractures of the hip in children from birth to adolescence. Clin Orthop Relat Res 92:155–187 [PubMed]
2. Ratliff AHC (1962) Fractures of the neck of the femur in children. J Bone Joint Surg Br 44:528–542 [PubMed]
3. Chrestian P, Bollini G, Jacquemier M, Ramaherison P (1981) Fractures du col du femur de lénfant. Chir Pediatr 22:397–403 [PubMed]
4. Ratliff AHC (1970) Complications after fractures of the femoral neck in children and their treatment. J Bone Joint Surg Br 52:175–183 .
5. Delbet cited by Colonna PC (1929) Fractures of the neck of the femur in children. Am J Surg 6:793–797.
6. RatliffAHC (1962) Fractures of the neck of the femur in children. J Bone Joint Surg Br 44:528–542[PubMed]
7. Pedro F. Tucci Neto, Fernando Baldy dos Reis, José Laredo Filho, , Edison Noboru Fujiki,Henri Bensahel, and Carlo Milani; Nonunion of fractures of the femoral neck in children ;J Child Orthop. 2008 Mar; 2(2): 97–103.
8. Amit Roshan, , The Neglected Femoral Neck Fracture in Young Adults: Review of a Challenging Problem; Clin Med Res. 2008 May; 6(1): 33–39.
9. Nagi ON, Dhillon MS, Gill SS.Fibular osteosynthesis for delayed type II and type III femoral neck fractures in children.J Orthop Trauma. 1992;6(3):306-13.
10. Miller WE (1973) Fractures of the hip in children from birth to adolescence. Clin Orthop Relat Res 92:155–187 [PubMed]
11. Rang M (1983) Children’s fractures. 2nd edn. J B Lippincott, Philadelphia
12. Canale ST, Bourland WL (1977) Fracture of the neck of the femur and intertrochanteric region of the femur in children. J Bone Joint Surg Am 59:431–443 [PubMed]
13. Ingram AJ, Bachynski B (1953) Fractures of the hip in children. J Bone Joint Surg Am 35:867–886[PubMed]
14. Lam SF (1971) Fractures of the neck of the femur in children. J Bone Joint Surg Am 53:1165–1179[PubMed]
15. Forlin E, Guille BA, Kumar SJ, Rhee KJ (1992) Complications associated with fracture of the neck of the femur in children. J Pediatr Orthop 12:503–509 [PubMed]
16. Hughes LO, Beaty JH (1994) Fractures of the head and neck of the femur in children. J Bone Joint Surg Am 76:283–291 [PubMed]
17. Colonna PC (1928) Fracture of the neck of the femur in childhood. Ann Surg 88:902–907[PMC free article] [PubMed]
18. Weiner DS, O’dell HW (1969) Fractures of the hip in children. J Trauma 9:62–79 [PubMed]
19. Durbin FC (1959) Avascular necrosis complicating undisplaced fractures of the neck of the femur in children. J Bone Joint Surg Br 41:758–765 [PubMed]
20. McDougall A (1961) Fractures of the neck of the femur in childhood. J Bone Joint Surg Br 43:16–28
21. Ogden JA (1974) Changing patterns of proximal femoral vascularity. J Bone Joint Surg Am 56:941–50[PubMed]
22. Trueta J (1957) The normal vascular anatomy of the human femoral head during growth. J Bone Joint Surg Br 39:358–373 [PubMed]
23. Chung SMK (1976) The arterial supply of the developing proximal end of the human femur. J Bone J Surg Am 58:961–970 [PubMed]
24. Sotto-Hall R, Johnson LH, Johnson RA (1964) Variations in the intra-articular pressure of the hip joint in injury and disease. J Bone Joint Surg Am 46:509–516 [PubMed]
25. Drake JK, Meyers MH (1984) Intracapsular pressure and hemartrosis following femoral neck fracture. Clin Orthop Relat Res 182:172–175 [PubMed]
26. Pauwels F (1965) Biomechanics of the locomotor apparatus. English edn. Springer, New York
27. Touzet P, Rigault P, Padovani JP, Pouliquen JC, Mallet JF, Guyonvarch G (1979) Fractures of the neck of the femur in children. Rev Chir Orthop Reparatrice Appar Mot 65:341–349 [PubMed]
28. Trueta J (1968) Vascular pattern of the femoral head during growth. In: Studies of the development decay of the human frame, 2nd ed. J. B. Lippincott, Philadelphia.

How to Cite this Article: Kumar EGM, Kumar GMY. Osteosynthesis in a 10 year old boy with fracture neck of femur, infected nonunion with implants insitu, neck resorption and Avascular Necrosis -A case report. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):48-50.

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Open reductions of Paediatric Supracondylar Humerus Fractures- When, How and, Risks

Vol 1 | Issue 1 | July-Sep 2015 | page:16-18 | Ashish Ranade, Gauri Oka.

Authors : Ashish Ranade[1], Gauri Oka[1].

[1] Dept. of Orthopaedics, Deenanath Mangeshkar Hospital, Pune 411004.

Address of Correspondence
Dr Ashish Ranade
Dept. of Orthopaedics, Deenanath Mangeshkar Hospital, Pune 411004.
Email address:ashishranade@yahoo.com

Abstract

Supracondylar humerus fracture is one of the commonest fractures in pediatric elbow. Usually closed reduction and percutaneous pinning is the preferred treatment for most of the displaced fractures. Nowadays closed reduction and percutaneous pinning has become standard of care for majority of displaced supracondylar humerus fractures. Rarely, an open reduction via appropriate approach becomes necessary. Various types of approaches that have been described are anterior, posterior, medial, lateral, and combined approaches. There is ambiguity of information as to selection of approach for doing open reduction in a supracondylar humerus fracture. There is debate about timing of treatment, approach selection and indications for doing open reduction.1 In this article we discuss indications, various types of approaches with their pros and cons and risks involved in open reduction of supracondylar humerus fractures in children.
Keywords: Supracondylar humerus fracture, open reduction, surgical approach.

Introduction
Supracondylar humerus fracture (SHF) is one of the commonest fractures in pediatric elbow. Nowadays closed reduction and percutaneous pinning has become standard of care for majority of displaced supracondylar humerus fractures. Rarely, an open reduction via appropriate approach becomes necessary. Various types of approaches that have been described are anterior, posterior, medial, lateral, and combined approaches. There is ambiguity of information as to selection of approach for doing open reduction in a supracondylar humerus fracture. There is debate about timing of treatment, approach selection and indications for doing open reduction [1]. In this article we discuss indications, various types of approaches with their pros and cons and risks involved in open reduction of supracondylar humerus fractures in children.

Case Example
A 9 year old boy was referred for the treatment of left supracondylar humerus fracture. He had sustained an injury following fall from a tree 10 days ago and was put in an above elbow splint in his village. On examination, radial pulse was present and he was neurologically intact.

The elbow was grossly swollen and there was deep abrasion with blister formation along the elbow crease on the anterior aspect. (Figure 1) There was ecchymosis along anterior aspect of elbow. The radiographs showed posterolaterally displaced type III supracondylar humerus fracture (Figure 2). Under general anaesthesia, closed reduction was attempted. Satisfactory reduction could not be achieved by closed means. Hence, a decision was made to perform open reduction. Considering the anterior wound, combined medial and lateral approach was chosen. Initially, a medial incision was made and the bony spike of the proximal fragment was separated from the brachialis fibres and the median nerve. At this point, reduction was attempted again. In view of difficulty in getting a satisfactory alignment, a lateral incision was made and the interposing tissues were removed. Periosteum was found to be torn on both sides. (Figure 3)After achieving open reduction, the fracture was fixed with crossed k wires and maintained in an AE slab for 3 weeks(Figure 4). Postoperatively, the patient made uneventful recovery and the fracture healed well in a satisfactory position. The elbow had 5 degrees loss of terminal flexion.

Discussion

Open reduction has been indicated for fractures with vascular injuries, signs of compartment syndrome, failure of closed reduction to achieve satisfactory alignment, and for severe swelling interfering to achieve good reduction [2-7]. In present day scenario, the main indication is failure to achieve satisfactory reduction by closed methods. This could be because of several factors such as instability of the fracture or interposition of neurovascular bundle or brachialis muscle. The overall proportion of supracondylar humerus fractures needing open reduction varies between 3 to 46% based on various studies[2,8-10]. This rate varies between centres and some centres may prefer to do open reductions than using closed methods. Delayed presentation of the fracture is one of the most important factors while discussing open reduction for supracondylar humerus fractures[ 5].
There are several options available for approach selection. There is no clear superiority of one approach over another. Mazzini and co-authors have published a systematic review of literature pertaining to surgical approaches in the treatment of open reduction and pinning[11]. In this review, authors found high frequency of poor results in terms of functional outcomes with posterior approach. High frequency of excellent results was found with the lateral and medial approach and a high frequency of good results within the anterior approach group. A Canadian study sites buttonholing of the proximal fragment through the brachialis muscle and interposition of joint capsule or periosteum between fragments[12]. With the posterior approach , anterior structures such as brachialis, and the neurovascular bundle cannot be accessed and probably the posterior scar leads to limitation of movements of the elbow joint[13]. In the same article, authors have found the change in the carrying angle (cosmetic outcome) as the most common complication seen after an open reduction via the posterior or lateral approach. However, relatively newer studies utilizing posterior approach do not report these complications [7,14]. Medial column communition and internal rotation and/or varus tilt of the distal fragment may be addressed sufficiently through lateral/posterior approach. In review by Mazzini et al, the time to union remains the same irrespective of the approach used. There was higher tendency of ulnar nerve injury in the posterior and lateral approach group. This is attributed to lack of direct visalization of ulnar nerve. Based on the findings, authors recommend anteromedial approach for open reduction[11].
While choosing an approach, one must take into consideration surgeon’s experience and the anatomical structures involved. It is known from various studies that fracture union time and rate of approach related complications are similar with various approaches [7,11].
In a study by Aslan and co-authors, clinical and radiographic results of children with Gartland type 3 supracondylar humerus treated with primary open reduction using four different approaches were studied [7]. Fifty eight patients were treated with either anterior, medial, lateral and , posterior approach. Choice of approach was decided by fracture pattern and neurovascular injury. All fractures were fixed with two lateral entry k wires or crossed k wires as per surgeon’s preference. In this series, three quarters of patients were operated within 24 hours since injury. Flynn criteria were used to measure outcomes. The outcome was comparable in all groups.
Ozkoc and co-authors studied 99 patients with supracondylar humerus fracture. In this group, 44 patients were treated with primary open reduction and k wire fixation and 55 were treated with closed reduction and percutaneous pinning. They found that in the open group the average loss of extension was 6 degrees compared to 0.6 degrees in the closed group[2].
Koudstaal and colleagues have reported the use of anterior approach in 26 children [15]. In another study, Ay and co-authors report their experience of using the anterior approach in 61 children [16]. In both these studies, a transverse incision was used in the antecubital fossa. In both studies, excellent results were noted without any significant loss of elbow movement.
In summary, various options are available for performing an open reduction of a supracondylar humerus fracture. The anterior approach certainly offers advantages of direct visualisation and retraction of entrapped structures. The treating surgeon must choose the appropriate approach based on the indication for open reduction.

Author’s preferred treatment
Our indications for open reduction are as follows:
1) Vascular compromise or disappearance of pulse after doing closed reduction- In this scenario, we suspect the brachial artery likely to be caught between fracture fragments. Hence, we perform an exploration via the anterolateral or anteromedial approach. The vascular structures are explored and reduction of fragments is achieved under vision. We undertake this approach with a vascular/plastic surgeon available in the operation theatre in case the need for vascular repair arises.
2) Inability to achieve satisfactory reduction by closed method- Usually this is encountered in late presentation of fractures with severely swollen elbow. Usually, attempts of closed reduction are made and if satisfactory reduction cannot be achieved, then open reduction is performed. Our preferred approach for this type is usually the anterior approach. However when skin conditions do not permit anterior approach, then a medial and/or lateral approach depending upon the fracture configuration is used.
Open fractures: Usually there is an anterior wound. Anterior approach is used in these cases.

References

1. Mulpuri K, Wilkins K. The treatment of displaced supracondylar humerus fractures: evidence based guideline. J Pediatr Orthop 2012;32:S143-S152
2. Ozkoc G, Gone U, Kayaalp A, Teker K, Peker TT. Displaced supracondylar humeral fractures in children: open reduction vs. closed reduction and pinning. Arch Orthop Trauma Surg 2004; 124:547-551.
3. Cramer KE, Devito DP, Green NE. Comparison of closed reduction and percutaneous pinning versus open reduction and percutaneous pinning in displaced supracondylar fractures of the humerus in children. J Orthop Trauma 1992;6:407-412.
4. Oh CW, Park BC, Kim PT, Park IH, Kyung HS, Ihn JC. Completely displaced supracondylar humerus fractures in children: results of open reduction versus closed reduction. J Orthop Sci 2003;8:137-141
5. Walmsley PJ, Kelly MB, Robb JE, Annan IH, Porter DE. Delay increases the need for open reduction of type –III supracondylar fractures of the humerus. J Bone Joint Surg Br 2006;88:528-530.
6. Mulhall KJ, Abuzakuk T, Curtin W, O;Sullivan M. Displaced supracondylar fractures of the humerus in children. Int Orthop 2000;24:221-223.
7. Aslan A, Konya MN, Ozdemir A, Yougancigil H, Maralcan G, Uysal E. Open reduction and pinning for the treatment of Gartland extension type III supracondylar humeral fractures in children. Strat Trauma Limb Recon 2014;9:79-88.
8. Aktekin CN, Toprak A, Ozturk AM, Altay M, Ozkurt B, Tabak AY. Open reduction via posterior triceps sparing approach in comparison with closed treatment of posteromedial displaced Gartland type III supracondylar humerus fractures. J Pediatr Orthop B 2008;17:171-178.
9. Gupta N, Kay RM, Leitch K, Femino JD, Tolo VT, Skaggs DL. Effect of surgical delay in perioperative complications and need for open reduction in supracondylar humerus fractures in children. J Pediatr Orthop 2004;24:245-248.
10. Reitman RD, Waters P, Millis M. Open reduction and internal fixation for supracondylar humerus fractures in children. J Pediatr Orthop 2001;21:157-161.
11. Mazzini JP, Martin JR, Esteban EMA. Surgical approaches for open reduction and pinning in severely displaced supracondylar humerus fractures in children: a systematic review. J Child Orthop 2010;4:143-152.
12. Fleiriau-Chateau P, McIntyre W, Letts WM. An analysis of open reduction of irreducible supracondylar fractures of the humerus in children. Can J Surg 1998;41(2):112-118.
13. Gruber MA, Hudson OC. Supracondylar fracture of the humerus in childhood. End results study of open reduction. J Bone Joint Surg Am 1964;46:1245-1252.
14. Sibly TF, Briggs PJ, Gibson MJ. Supracondylar fractures of the humerus in childhood: Range of movements following the posterior approach to open reduction. Injury 1991;22(6):456-458.
15. Koudstaal MJ, De Ridder VA, De Lange S, et al. Pediatric supracondylar humerus fractures: The anterior approach. J Orthop Trauma 2002;16(6):409-412.
16. Ay S, Akinnci M, Kamiloglu S, Ercetin O. Open reduction of displaced pediatric supracondylar humeral fracture through the anterior cubital approach. J Pediatr Orthop 2005;25:149-153 .

How to Cite this Article: Ranade A, Oka G. Open reductions- When, How and, Risks. International Journal of Paediatric Orthopaedics July-Sep 2015;1(1):16-18.

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Osteosynthesis in a 10 year old boy with Fracture neck of Femur, Infected Nonunion with Implants In-situ, Neck Resorption and Avascular Necrosis -A case report.

Open reductions of Paediatric Supracondylar Humerus Fractures- When, How and, Risks

Osteosynthesis in a 10 year old boy with Fracture neck of Femur, Infected Nonunion with Implants In-situ, Neck Resorption and Avascular Necrosis -A case report.

Open reductions of Paediatric Supracondylar Humerus Fractures- When, How and, Risks

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Osteosynthesis in a 10 year old boy with Fracture neck of Femur, Infected Nonunion with Implants In-situ, Neck Resorption and Avascular Necrosis -A case report.

Authors : EG Mohan Kumar[1], GM Yathish Kumar[1].

Abstract

References

(Abstract) (Full Text HTML) (Download PDF)

Open reductions of Paediatric Supracondylar Humerus Fractures- When, How and, Risks

Authors : Ashish Ranade[1], Gauri Oka[1].

Abstract

References

(Abstract) (Full Text HTML) (Download PDF)

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