This document discusses fractures of the femoral shaft in pediatric patients. Key points include: flexible intramedullary nailing has become the preferred treatment for most fractures due to low complication rates; plating and external fixation are options for more complex fractures or open injuries; and rigid intramedullary nailing carries a risk of avascular necrosis of the femoral head due to its blood supply. The goals of treatment are to restore alignment and length while avoiding growth plate injury or disruption of the femoral head blood supply.
Osseous anatomy, Types of approaches(Position,landmarks,Incision,Superficial and Deep surgical dissection) , structures at risk, Extensile approaches with diagrams and eponymous .
Bone fractures are a very common orthopedic injury resulting from trauma and sudden loads or stresses applied to bones or a result from bones being weakened by certain diseases. More than 250,000 femur fracture patients are seen per year in the U.S. on average. Bone fractures are either a complete or partial break in a bone and in some cases a simple cast to immobilize the injury site is not enough to completely heal the fracture.
Immobilization from casts may not be enough to completely heal the fracture if a malunion (when both ends of the fractured bone misalign) occurs and/or if a non-union (when the fracture gap is too large and the fractured ends cannot re-attach to one another) occurs. In the case of a malunion or non-union, a possible solution to the problem is by surgically inserting an intramedullary rod into the center canal (diaphysial) region of the injured bone and fixating it into place with screws.
Osseous anatomy, Types of approaches(Position,landmarks,Incision,Superficial and Deep surgical dissection) , structures at risk, Extensile approaches with diagrams and eponymous .
Bone fractures are a very common orthopedic injury resulting from trauma and sudden loads or stresses applied to bones or a result from bones being weakened by certain diseases. More than 250,000 femur fracture patients are seen per year in the U.S. on average. Bone fractures are either a complete or partial break in a bone and in some cases a simple cast to immobilize the injury site is not enough to completely heal the fracture.
Immobilization from casts may not be enough to completely heal the fracture if a malunion (when both ends of the fractured bone misalign) occurs and/or if a non-union (when the fracture gap is too large and the fractured ends cannot re-attach to one another) occurs. In the case of a malunion or non-union, a possible solution to the problem is by surgically inserting an intramedullary rod into the center canal (diaphysial) region of the injured bone and fixating it into place with screws.
Imaging anatomy fractures of the femurAkram Jaffar
After completion of this session, students should be able to discuss, identify, and describe:
The anatomical factors predisposing to the etiology of a fracture or dislocation.
The anatomy of displacement or deformity.
Imaging anatomy features and how to differentiate from epiphyseal lines.
Anatomy related to correct relocation and alignment.
Anatomical complications of a fracture or dislocation.
Young adult with primary fixation cutting through was treated after six months of initial injury.
Head viability was confirmed by MRI and to have bio mechanical advantage, abduction or valgus osteotmy was carried out resulting in good functional result at the end of 10 months when last seen
Intramedullary nailing of fractures.dr mohamed ashraf.HOD.govt TD medical co...drashraf369
presentation of biology,biomechanics and practice of intramedullary nailing of long bone fractures by dr mohamed ashraf,govt TD medical college,alleppey,kerala,india
paediatric monteggia fracture dr mohamed ashraf alleppey kerala india.pptxdrashraf369
paediatric monteggia fracture is often missed especially by less experienced orthopaedic surgeon.
once missed ,it can lead to progressive deformity of the elbow,restricted elbow and forearm movements.
subsequent management is often less satisfactory and give inferior results.
a high degree of suspicion is often needed in all pediatric elbow injuries brought to the emergency department.
the presentation is by prof.mohamed ashraf ,head of the department of orthopaedics. govt TD MEDICAL COLLEGE,ALLEPPEY,KERALA, INDIA
Many people assume that getting braces removed is the end of the orthodontic process but actually further care is required to avoid orthodontic relapse.
Hello ...im dr zamin abbas...i completed my residency from shifa international hospital islamabad...these are one of my presentations i want to share with other colleagues
Fracture shaft of tibia is a very common injury which we deal as a trauma surgeon
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
4. Treatment Goals - Avoid
• Osteonecrosis - disruption of blood supply
to femoral head
• Physeal injury- preserve future growth
potential (proximal and distal femoral
physes, trochanteric apophysis)
5. Anatomy and Growth
• Proximal femoral physis- 30% of
longitudinal growth
• Distal femoral physis- 70% of longitudinal
growth
• Trochanteric apophysis- most of
trochanteric growth appositional after age 8
years
6. Anatomy- Blood Supply
Proximal Femoral Epiphysis
• Predominantly
ascending cervical
branch (B) of medial
circumflex femoral
artery
• Physis (D) - a barrier
to intraosseous blood
supply from femoral
neck
Chung S. JBJS 58A, 1976
7. Pediatric Femur Fractures-
Mechanism of Injury
• Rule out NAT in children <1year old
• Falls- young children/toddlers
• Struck by car- juvenile
• Recreational sports/activities- adolescent
• Motor vehicle crashes- all age groups
8. Mechanism of Injury
• Low Energy
• High Energy
*predicts
behavior/treatment of the
fracture (Blount-1973,
Pollack-1994)
9. Pediatric Femur Fractures-
Associated Injuries
• Struck by car- triad of femur fracture, torso
injuries, head injury
• Potential damage to physes of femur and
proximal tibia
• Head Injury – spasticity can make traction
and cast treatment difficult
• Abdominal injury – spica cast can constrict
abdomen and limit ability to examine
10. Physical Exam
• Complete exam: head, chest, abdomen, and
other skeletal segments
• Document distal neurologic and vascular
function
• Palpate all bones
• First Aid principles - Splint or traction
12. Classification
• Open or closed
• Location of fracture- subtrochanteric,
diaphyseal (proximal, mid, distal third),
supracondylar
• Fracture pattern- transverse, spiral, oblique,
comminuted, greenstick
• Amount of shortening
• Angular deformity
13. 7 Principles
Dameron & Thompson JBJS 1959
• 1. Simplest treatment best
• 2. Initial treatment permanent when
possible
• 3. Perfect anatomic reduction not essential
for perfect function
• 4. More potential growth= more
remodeling capability
14. Dameron & Thompson
JBJS 1959
• 5. Restoration of alignment more important
than fragment position
• 6. Overtreatment usually worse than
undertreatment
• 7. Immobilize/splint injured limb before
definitive treatment
15. Decision Making
• Age
• Mechanism of injury
• Fracture pattern & location
• Associated Injuries
• Surgeon preference
16. Traction Techniques
• Skin or skeletal
• Avoid physes if place skeletal traction pins
• Place pin perpendicular to shaft to avoid
varus/valgus angulation
• Longitudinal in line traction for comfort
prior to definitive treatment
• Split Russells traction (90-90) if awaiting
early healing prior to casting
17. Immediate or Early
Spica Cast-Ideal Patient
• Less than 5 years old
• Less than 100 lbs
• Initial shortening not excessive
• Isolated injury
• Note -Spica casts used for decades and can
work for almost any pediatric femur
fracture
18. Spica Cast Technique
• Appropriate padding
• Cast liners may decrease skin problems
• Traction to get 0-15 mm shortening
• Mold laterally to prevent varus
• Can wedge for unacceptable angulation at
1 week check
(>10-20° varus/valgus, >15-30°
procurvatum/recurvatum – age dependent)
19. Immediate Spica Cast
• Fiberglass lighter, easier to x-ray through
• Often strong enough to obviate need for
connecting bar
• See Kasser AAOS Instructional Course
Lectures Volume XLI, 1992
20. Immediate Spica Cast
• X-ray weekly for 3 weeks
• Time in spica= age in years + 3 weeks up to
maximum 8 weeks
• Wedge cast for malalignment
• Rotational alignment important at initial
cast application
23. Femoral Remodeling
after Fracture
• Will not correct significant rotational
malunion
• Overgrowth 1-1.5 cm may occur, especially
in younger children treated nonoperatively
• Angular deformity will remodel
significantly in children <5 years old, less
reliably in 5-10 year old, and is unlikely to
be substantial in children >10 years old
25. ORIF with Plates/Screws
• Advantages – rigid, technique familiar to
most surgeons, allows early motion,
favorable results reported in children with
associated head injuries
• Disadvantages- large scar, possible
refracture after plate removed, higher
infection rate in some earlier series
27. External Fixation
• Advantages – can be applied rapidly, allows
soft tissue injury management , early
mobilization, avoid cast
• Disadvantages- pin site sepsis, pin site
scarring, refracture, malunion
28. 11 yo male MVC
Pelvic fracture, ruptured bladder
External fixation
29. External Fixator Tips
• Appropriate size half pin diameter
• Proper pin placement relative to fracture for
biomechanical rigidity
• Do not remove ex fix until see bridging
cortices (3 or 4 of 4)
30. Open Femur Fracture
Principles
• IV antibiotics, tetanus
prophylaxis
• emergent irrigation &
debridement
• skeletal stabilization
• External fixation best
option with severe soft
tissue injury
• soft tissue coverage
32. Flexible Nailing
• Advantages – allows early mobilization
without cast, cosmetic scars, avoids physes
and blood supply to femoral head
• Disadvantages – later nail removal, ends
may irritate soft tissues, may not be
amenable to some fracture patterns (very
proximal or distal, comminution)
33.
34. 12 yo male in ATV accident
Closed proximal third, oblique
Back at school 2 weeks
Walking at 8 weeks
35. Titanium Elastic Nailing - Results
Flynn et al. JPO Jan 2001
• 57/58 excellent or satisfactory
• No rotational malunions
• 6/58 – 1-2 cm LLD
36. Titanium Elastic Nailing -
Complications
Flynn et al. JPO Jan 2001
• 5/9 proximal fx - > 5 degree angulation
• 1 refracture after nail removal
• 4/58 prominent nails – 1 premature
removal
• 1 poor result – 11 yo, 15 mm short, 20
degrees varus
37. Flexible Nails
• Multiple studies from
multiple institutions
now report excellent
outcomes with few
complications
• If fracture pattern
allows this is the
preferred method of
fixation for many
38. Rigid Nailing
• Advantages – rigid fixation, control rotation
with interlocking screws
• Disadvantages -Risks injury to proximal
femoral epiphysis (rare but possible
devastating complication of osteonecrosis),
may interfere with trochanteric growth
39. Why Not Use Rigid Nail?
Concern about AVN / osteonecrosis
of the femoral head
41. Piriformis Fossa Entry Site
Raney E. JPO, 1993.
Thometz J, JBJS 1995.
Astion D, JBJS 1995
42. The Data –
English Literature
• Estimated AVN Prevalence = 1-2%
– 1996 POSNA membership survey
– 15 cases identified
– All following Rigid Reamed Nail
– None following flexible nailing
– 1 published case after trochanteric entry
• 6 Published Case Reports
• 13 Published Case Series
45. IM Nailing vs. Non-op Treatment
• Kirby et al., JPO 1981
– Traction / Spica vs. Closed IM Nailing
• Herndon et al., JPO 1989
– Traction / Spica vs. Closed IM Nailing
# Pts. Avg Age Union Hosp stay Results
Spica 24 13 +3 11.5 wk 28 d Malunion (7), >2.5 cm short (3)
Nail 21 13 +9 10 wk 17 d
# Pts. Avg Age Hosp stay Results
Spica 13 12 +8 30.5 d Malunion (4), >2.5 cm short (2)
Nail 12 14 +0 20.6 d Trochanteric Arrest (1)
46. IM Nailing vs. Non-op Treatment
• Reeves et al., JPO 1990
– Traction / Spica vs. Internal Fixation
• 30 Kuntscher Rods
• 19 Plates
# Pts. Avg Age Hosp stay Cost Results
Spica 41 12 +4 26 d 11,800 Delayed union (4), Malunion (5),
Growth disturbance (4), Psychotic
Episodes (2)
Internal Fixation 49 14 +11 9 d 8,100 Transient Peroneal Palsy (1)
47. Trends in Pediatric Femur
Fracture Management
• Much less frequent traction- casting
• Immediate spica if <5 years old
• Flexible nailing for patients 5 years old to
skeletal maturity
• External fixation, plate fixation less
commonly used
• Submuscular plating for certain fracture
patterns
48. Trends
• Trochanteric entry rigid
nailing- new designs,
large experience in some
centers
• Limited/minimal incision
plating techniques- bridge
plate concept- popular in
few trauma centers, useful
for some fracture
patterns/locations
• External fixation for
severe soft tissue injuries
in open fractures
52. 12 yo 200 lb female – unstable fx
treated with flexible nails – healed
with 30 degree procurvatum malunion
53. 13 yo male hit by car
Initially 2 retrograde TEN
1 became prominent
Healed 5 cm short
Lengthened over nail Healed with equal LL
Courtesy of
S.H.Sims, MD
54. Trend Toward More
Invasive Treatment
• More high energy fractures
• Improved operative techniques
• Failed nonoperative treatment
• Simplifies patient care
• Psychological, social and financial reasons
55. Timmermann and Rab
JOT 1993
• “Most children with fractures of the femur
have a satisfactory outcome with any
reasonable form of treatment.”
Return to
Pediatrics Index
Editor's Notes
As depicted in this drawing, the epiphyseal blood supply traverses the piriformis fossa.
Chung, Ogden, and Truetta showed in separate studies that the lateral ascending branch on the anatomic ring at the base of the femoral neck provides the main blood supply to the lateral aspect of the femoral neck and to the lateral and superior parts of the capital femoral epiphysis.
This artery lies I close proximity to the most common point of entry of an IM nail.
Damage to this arterial system is the most commonly cited cause of AVN of the femoral head.
Now that the anatomy and technique are clear lets look at what the studies show.
1996 POSNA survey
6 case reports (1994-1997)
I will detial these.
13 published series including one prospective trial.Summarize in a table the finding and then focus on those with a complication of AVN
There are 13 published series.
From 1981 to 2000.
The first three I mentioned earlier for they compared IM nailing to conservative treatment.
KIRBY REEVES HERNDON
The next couple with the following compliaitons
Beaty , Buford and Stns had eports of AVN .
In the end, there are 334 patients that under went rigid IM nailing.
4 of these or a little more than 1% had documented AVN.
Lets look at those 4.
To evaluate the results of IM nailing in this specific age group of 10-15, Kirby (1981) compared closed IM nailing with a Kuntscher nail to traction plus casting. to conservative treatment
Herndon conducted a similar study in 1989.
Kirby’s was a retrospective study of the two methods used at two different hospitls in Seattle in the 1970’s.
His findings were 2 of the 13 in the non-surgically treated group had significant shortening. Both required corrective surgery.Non e of the 13 fractures in the nailed group had significant complications. No malunions occurred. No infections. One intraoperative issue was a splitting of the lateral cortex of the proximal fragment There was one case of an asymptomatic presumed arrest of the trochanteric apophysis.
FU was an average of 16 months
herndon retrospectively reviewed 44 patients that underwent treatment for shaft fxs. Seven malunions ocurred in the non op group. None occurred in the 21 fx treated by Im nailing.
Hospital stay was significantly shorter in the operatively treated group.
No premature growth arrest or AVN was noted in the surgical group.
FU averaged 24 months
Reeves reviewed 90 adolescents with 96 femur fx. 49 underwent rigid fixation (30 nails and 19 plates. 41 underwent traction and subsequent hip spica casting. There were no malunions, nonunions or infections in the operative group. However there were 4 delayed unions and 5 malunions in the traction and spica group
Also not e the psychological complications in the conservatively trated group.
. One patient in the operative in group had a plate break before healing and one had a transient peroneal palsy.
The authors concluded that surgical stabilization was superior to traction and hip spica casting.