Distal femur in paediatric age group

1. SUSHANT S. SONARKAR
DEPT OF ORTHOPAEDICS
 PAEDIATRIC DISTAL
FEMORAL INJURIES

2. PAEDIATRIC KNEE ANA
TOMY
• Formed from single ossific nucleus, first present
at birth and is first epiphysis in body to ossify.
• Grows at a rate of 8-10 mm per year.
• Contributes 40% of growth of lower extremity.
• Closes at 13 years in girls and 15 years in boys.

3. • The distal femur has a classic rhomboid shape
and inclination of joint line at knee.
• Anatomic axis-9 degree.
• Mechanical axis-3 degree.

4. • The muscular attachment of gastrocnemius and
plantaris is on posterior aspect of distal femoral
metaphysis, proximal to physis, hence flexion.
• Adductor magnus attached to medial aspect of
femoral metaphysis, hence varus.
• Collateral ligaments attach at the level of
epiphysis.

5. SALTER HARRIS
CLASSIFICATION
1 – Through the physis
2 – Involving the metaphysis
3 Involving the epiphysis
4 Through metaphysis and epiphysis
5 - Impacted

6. Mechanism of injury
AGE
• Newborn period -breech presentation- type 1 SA
• In 3-10 years, severe trauma, rarely sports injuries
• In adolescents more of sports injuries
DIRECTION OF FORCE
• Valgus type of force
• Hyperextension force

8. Unique Pediatric Principles
• FASTER HEALING
– Less robust fixation is typically sufficient
• REMODELING
– Extra-articular imperfect reductions are acceptable in many cases
– Fractures closest to the physis, with deformity in the plane of motion have
highest remodeling potential
• LOWER CHANCE OF STIFFNESS
– Casting/immobilizing limbs to augment fixation
– Non-operative treatments using casting
• THE PHYSIS
– “The gift that keeps on giving”
– Injury to the physis (at the time of injury OR due to treatment) will continue to
present problems until skeletal maturity
• RESPECT THE PHYSIS
– Limit manipulation of the physis to 7-10 days post-injury
– When reducing – 90% of force in traction, 10% in translation

9. Distal Femoral Physis
Significant Anatomy:
– Popliteal and geniculate arteries
• Located posterior to distal metaphysis and capsule
• Displaced fractures can compromise vascular flow
– More problematic in proximal tibial physeal injuries
– Distal Femoral physis is highly undulating
• Fractures involving the physis have 30-70% risk of
permanent growth disturbance

10. Distal Femoral Physeal Fractures
Fracture Epidemiology:
– Rare, only accounts for <1% of fractures
– Mechanism:
• High energy trauma
• Sports injuries account for 2/3 of distal femur
fractures
• Varus/ Valgus force
• Hyperextension of knee
• Physis typically fails under traumatic force
before ligaments in children

11. Distal Femoral Physeal Fractures
Physical Examination :
– Effusion
– Soft tissue swelling
– Tenderness over physis – as opposed to isolated medial tenderness
for MCL sprain
– Anteriorly displaced or hyperextension injuries cause patella to
become more prominent and anterior skin often dimpled
– Posterior displacement can cause the distal metaphyseal fragment
to become more prominent above the patella
– Inability to Weight Bear

12. Distal Femoral Physeal Fractures
• Always consider vascular
compromise
• Knee dislocation equivalent
• Perform AND document
– Peripheral pulses
– Compartment evaluation
– ABIs (Ankle-Brachial Index)
• Reduce emergently if
vascular compromise
– Re-assess after reduction
• Monitor for swelling.

13. Distal Femoral Physeal Fractures
• Associated injuries
– Ligamentous
– Vascular
– Nerve (peroneal if anteromedial displacement)
• Radiographs
– AP & Lateral
– Oblique View
– Contralateral comparison
– Stress X-ray – rarely utilized due to pain
– CT – helpful in evaluating fracture complexity
• Surgical planning for fixation of metaphyseal fragment with
screws
– MRI
• For occult injuries or ruling out concomitant ligamentous/
meniscal injuries

14. Distal Femoral Physeal Fractures
• Classification:
– Salter Harris (I and II most common)
– Displacement
• Anterior/Posterior
• Varus/Valgus
• Treatment:
– Closed reduction
• Immobilization (cast, splint, brace)
• Percutaneous pinning
• Screw fixation
– Open reduction
• Options as above
• Plate fixation (transitional age group)
• Essentially all Salter-Harris III and IV intra-articular fractures

15. Distal Femoral Physeal Fractures
• Closed reduction and casting:
– Non-displaced/stable fractures
– Remodeling best in the flexion/extension plane
– Do NOT manipulate after 7-10 days
• Early and rapid healing of physis
• Delayed manipulation risks iatrogenic physeal injury
– Splint in slight knee flexion
– Partial weight bearing at 3-4 weeks
• Closed reduction and internal fixation:
– Reduction performed with traction and angular correction
– Fixation should avoid physis if possible or cross with small
diameter smooth pins
– Splint/Cast x4 weeks with pins
– Almost always supplement reduction with fixation
• Prevent recurrent displacement

16. Distal Femoral Physeal Fractures
• Outcomes:
– Risk of damage to growth plate & growth disturbance
– Growth disturbance likely to occur in younger patients with
fractures that are displaced more than ½ the diameter of the shaft
(Thomson JPO 1995)
– Check leg length, alignment, gait at 6 months (follow for 24
months) (Zionts JAAOS 2002)
– Leg length inequalities:
» <2 cm at skeletal maturity  nonsurgical
» 2-5 cm  appropriately timed epiphysiodesis of
contralateral leg
» >5 cm  leg lengthening should be considered
– Angular deformities managed by osteotomies or
hemiepiphysiodesis

17. CLINICAL FEATURES
• Acute distress secondary to pain
• Knee is in flexed position
• Deformity
• Ecchymotic areas indicate deforming forces
• Look for swelling in popliteal region
• Neurovascular examination is the must

18. RADIOLOGY
• Xrays
• Stress views
• CT
• Mri
• Ultrasound
• X-rays should be compared with contralateral physis

19. TREATMENT
• Closed reduction,percutaneous pinning and cast
conversion is preferred
• Anatomical reduction with acceptable residual
angulation in sagittal plane 20 degrees <10
degree in child
• No rotational misalignment accepted
• <5 degree varus and valgus

20. EXTERNAL FIXATION
• Soft tissue injury with open fracture
• Poly trauma patient with urgent satbilization
• Highly communited fracture
• Fracture is reduced primarily
• With two pins proximal to fracture site and two
pins in the distal metaphyseal fragment
• Placed atleast 1cm away from physis and
parallel to knee joint line from lateral
• And fluoroscopically checked in extension and
realigned if any malalignment

21. CLOSED REDUCTION AND INTERNAL
FIXATION
• Hyperextension type of injury-distal fragment
is flexed by pull of gasrtocnemius and proximal
fragment is posteriorly placed
• Hyperflexion type-distal fragment is flexed and
proximal fragment is anterior

23. OPEN REDUCTION AND INTERNAL FIXATION
• Irreducible
• Require stable fixation such as arterial injury
• M0st common reason for failure is proximal
fragment buttonholing of the quadriceps,Standard
lateral approach , if arterial injury then medial
approach

26. NOTE-
Salter and colleagues stated that when
excessive ,manipulation appears to be necessary
to achieve acceptable reduction,it is better to
maintain growth potential and perform
corrective osteotomy at a later date than
overstress to physis

27. COMPLICATIONS
Complications
Acute
Arterialinjury
Peroneal
nerve injury
Ligamnetous
injury
Loss of
reduction
late
PhysealArrest
Angular
deformity
Loss ofknee
motion

28. Arterial injury
• Rare in distal ephiphyseal injury
• Common in complete separation of physis in a
hyperextension injury
• Hence after reduction in case of discrepency
between two limbs then pulse is checked
• Arterial injury requires stable fixation via medial
approach
• Sometimes, Fasciotomy if needed

29. Peroneal nerve
injury
• Direct trauma on posterolateral aspect of leg
• Varus producing injury causing over stretching
• All injuries resolve by 6 month period
• If no improvement for 3 months NCV to be
done and explored and nerve grafting or direct
repair

30. Ligamentous
injury
• Most commonly involved is ACL followed by
LCL then MCL
• Even meniscal injury possible
• It is difficult to diagnose at time of injury and
should be evaluates soon after union

31. Loss of reduction
• Due to suboptimal stabilization of unstable
fracture
• Not immobilized in cast
• No flexion in anteriorly displaced
• No extension in posteriorly

32. Physeal arrest
Risk factors
• High energy trauma
• Juvenile age group
• Severly displaced fractures
• Communited fractures

33. • Physeal fractures thoroughly evaluated by CT
• Physeal bar resection when <50% physis is
involved and the growth remaining is atleast
2.5cm
• Limb lengths should be plotted on moseley
straight line graph over a 1 to 2 year period to
determine the projected discrepency at skeletal
maturity

34. • No treatment is indicated if <2cm of discrepency
• Between 2 to 6 epiphysiodesis of
contralateral distal femur or proximal tibia
• Large discrepency should be treated by femoral
lengthening procedure

35. ANGULAR DEFORMITY
• Less seen than limb length discrepency
• Risk factors and indication for physeal bar
resection are the same
• Treatment indicated >5 degree of abnormal
angulation is present consists of angular
corrective osteotomies or ephysiolysis

36. Loss of knee
motion
• Excessive duration of immobilization
• In SH type 3 and 4 due to articular incongruities
It can be Prevented by
-Restricting the duration of immobilization
-Removing k wires as soon as possible
-Anatomic redution of intrarticular fractures

37. CASE
PRESENTATIONS

38. CASE 1
 NAME - Master RUDRA RAJ SINGH
- S/0 SGT RANDEEP SINGH
 AGE - 08 YRS
 UNIT - 10 WG
 DIAGNOSIS - DISTAL FEMUR FRACTURE RIGHT KNEE
 MODE OF INJURY -FALL WHILE PLAYING IN PLAYGROUND
 DATE OF INJURY -28 APR 19
 DATE OF SURGERY - 28 APR 19 ( CRPP - SURGERY DONE IN
EMERGENCY)

39. Salter Harris I

41. CASE 2
 NAME - Master KARTHIK
- S/0 CPL KARAN DEV
 AGE - 09 YRS
 UNIT - 11 WG TEZPUR
 DIAGNOSIS - DISTAL FEMUR FRACTURE RIGHT KNEE
 MODE OF INJURY -FALL WHILE SWINGING IN PLAYGROUND

42. Salter Harris I

43. Salter Harris I -
CRPP
After
provisional
urgent
reduction and
reassessment of
NV status

44. Salter Harris I -
CRPP
• Options
– Antegrade percutaneous pin fixation
• Avoids pin placement into the knee joint
• Decreases risk of septic arthritis
– Retrograde percutaneous pin fixation
• Easier to place pins (more superficial starting point
• Recommend burying to decrease infection risk
• Removal at 6 weeks (if buried), 4 weeks if exposed
• Always supplement pin fixation with a splint/cast

45. CASE 3
 NAME - Master ASHISH
- D/0 SGT GOKUL
 AGE - 11 YRS
 UNIT - 10 WG
 DIAGNOSIS - CONTUSION RIGHT KNEE
 MODE OF INJURY -FALL FROM STAIRCASE
 DATE OF INJURY -16 MAR 19

46. 11 yr Male child with
right knee pain
immediate after being
tackled in football in
air force school.
Minimally displaced SH1
distal femur fracture
missed
Salter Harris 1- Subtle Injury

47. Fracture treated closed, did not require reduction
At follow up, physeal arrest noted
Expect a significant leg length discrepancy at 5 years of growth

48. CASE 4
 NAME - Miss KHUSBOO
- D/0 CPL RAJEEV KUMAR
 AGE - 05 YRS
 UNIT - 14 WG CHABUA
 DIAGNOSIS - DISTAL FEMUR FRACTURE RIGHT KNEE
 MODE OF INJURY -FALL FROM LADDER
 DATE OF INJURY -28 JAN 20
 DATE OF SURGERY -31 JAN 20 ( MINI OPEN OVER LATERAL
FEMORAL CONDYLE )

49. PRE OP X-RAYS Salter Harris
II

50. Distal Femoral Physis
Fractures• Open Reduction
– Indications
• Fractures that cannot be reduced closed
– Interposed periosteum
• Open and displaced fractures
• Floating knees
– Pre-operative CT can assist with surgical planning
• Define plane of metaphyseal spike to planned pinns or
screw trajectory
– Technical tip –
• The metaphyseal spike side will have intact
periosteum covering in – open the fracture on the
OPPOSITE side to remove interposed periosteum.

51. INTRA OPERATIVE X-
RAYS

52. POST OP X-RAYS Salter Harris II -
ORPP

53. AFTER 06 MONTHS

54. Summary
• Pediatric Knee injuries present unique challenges due to
the physis
• Monitor for neurovascular injuries, skin compromise,
and compartment syndrome with knee injuries (despite
benign-appearing radiographs)
• Pediatric patients have a lower chance of stiffness so
fixation can be supplemented with immobilization
• Articular injuries in kids still require anatomic reduction
• Avoid crossing the physis with fixation unless near
skeletal maturity or using small-diameter smooth
provisional pins

55. THANK YOU & HAVE
A GOOD DAY AHEAD