Management of neglected distal femur epiphyseal fracture-separation

Minimally Invasive Percutaneous Leverage Reduction in the Treatment of Pediatric Salter-Harris IV and V Distal Femoral Physeal Fractures

OBJECTIVE

Distal femoral physeal fractures (DFPF) are rare but severe injuries in children, and there is no consensus on treatments for Salter-Harris (S-H) IV and V type of DFPF yet. This study aimed to introduce a minimally invasive technique using percutaneous leverage reduction combined with Kirschner wires fixation in treating pediatric DFPF with S-H IV and V type of injury and evaluate the clinical results.

METHODS

From July 2008 to June 2018, the authors' institute (Union Hospital, Tongji Medical College) retrospectively reviewed all patients diagnosed with pediatric DFPF. They were divided into two groups according to received treatment: children in the minimally invasive technique group were treated with a minimally invasive percutaneous leverage reduction technique, and the traditional technique group included the other children who received the conventional open reduction with internal fixation (ORIF). The surgical and clinical results of the two groups were collected and analyzed. The independent sample t-test analysis and the chi-square test were applied to compare continuous and categorical variables.

RESULTS

A total of 14 pediatric patients were recruited, including five females and nine males with DFEF. All eight patients in the minimally invasive technique group and four of the six patients in the ORIF group were treated successfully. One patient in the minimally invasive technique group opted for conservative treatment due to his good functional recovery, while the other two patients in the ORIF group needed further surgery because of the limb length discrepancy. There was a difference in surgery duration (p < 0.001), intraoperative fluoroscopy numbers (p = 0.006), intraoperative blood loss (p < 0.001), radiological union time (p = 0.003) and knee flexion angle (p < 0.001) between two groups. Patients in the minimally invasive technique group all received total knee society (KSS) scores, while the average scores in the ORIF group were lower (100.00 vs. 97.67).

CONCLUSION

The minimally invasive technique is better than conventional ORIF in terms of surgery duration, intraoperative blood loss, radiological union time, knee flexion angle and average KSS score. This percutaneous leverage reduction technique might be a good alternative for treating S-H IV and V DFPF in children.

Management of neglected post-traumatic ipsilateral distal femoral and proximal tibial epiphysiodeses in adolescent: Case report

Introduction

It is important to remember the risk of post-traumatic epiphysiodesis in the context of high-speed impacts around the knee. This clinical case illustrates the risk of lower limb length discrepancy resulting from this, the treatment and management thereof. This case is unique in that it presents two ipsilateral distal femoral and proximal tibial epiphysiodeses, with secondary inequality of these two bone segments.

Case presentation

A 13-year-old adolescent is managed for a displaced diaphyseal fracture of the distal femur. He undergoes surgery for this fracture. He suffered high velocity trauma and is also likely to have suffered Salter V trauma to his distal femoral and proximal tibial ipsilateral physes. The consequence is an unequal length of the tibias and femurs. A femoral lengthening is performed and allows to restore a symmetry of the femurs. The asymmetry of the tibias is neglected, and a residual asymmetry persists and will be corrected later.

Discussion

The important elements on the management of high-speed trauma around the knee are recalled. A good assessment of bone growth is necessary and individualized treatment should be chosen. This case is particularly interesting because of the nature of the injuries, their consequences and their treatment. Unfortunately, neglecting the suspicion of physes injuries (especially in proximal tibial) is to be noted.

A 3-Level Impaction Technique for Dorsal Reshaping and Reduction Without Dorsal Soft Tissue Envelope Dissection

BACKGROUND

Preservation rhinoplasty (PR) techniques are continuously evolving and many variations of established techniques have been proposed since Daniel coined this term in 2018.

OBJECTIVES

The aim of this study was to describe indications for a new "3-level impaction" technique, allowing, in selected cases, a complete profile correction and dorsal reduction without dissection of the dorsal soft tissue envelope (STE).

METHODS

Three hundred and fifty primary closed rhinoplasty cases were retrospectively studied from January 2018 and October 2019. Age, sex, race, technical details, surgical time, and complications were registered. Ninety-five dorsa were reduced and shaped without dissecting the dorsal STE by combining: (1) a swinging-door septoplasty with low septal strip resection, (2) endonasal bony cap mosaic osteotomies, and (3) let-down or push-down operation.

RESULTS

All patients showed a dramatic change in profile height and shape without either dorsal STE dissection or bony cartilage dorsal tissue resection. Mosaic osteotomies converted the dorsal keystone area from S- to V-shaped dorsum, let-down-operation and low septal strip resection enabled impaction, and profile setting was achieved by quadrangular cartilage flap rotation. The average follow-up time was 14 months (range, 12-16 months).

CONCLUSIONS

In selected patients, dorsum can be preserved without STE dissection. By combining multiple endonasal maneuvers it is possible to obtain a dramatic change without dissecting the STE, while simultaneously avoiding any dorsal tissue resection. This method offers a versatile technique in selected patients, which leads to fast recovery and natural results.

LEVEL OF EVIDENCE: 4

Reduction of Neglected Displaced Fractures of the Distal Femoral Physis

Background

We performed open osteoclasis, soft-tissue release, and fracture fragment reduction and fixation to treat 10 cases of neglected physeal fractures of the distal aspect of the femur with severe deformity. To our knowledge, no specific surgical procedure for this problem has been reported in the literature.

Description

The procedure is typically performed through an extensile anterolateral approach. With use of an osteotome, the typically abundant fracture callus is disrupted and partially removed to recreate the original fracture line. Through periosteal dissection, an extensive musculoperiosteal detachment and release is achieved to facilitate fracture reduction while protecting the physis from further injury.

Alternatives

Knee rehabilitation in closed, nondisplaced or minimally displaced fractures¹.Open callus osteoclasis in combination with a Z-shaped quadriceps tenoplasty, reduction, and plaster cast immobilization².Open subperiosteal osteoclasis, reduction, and tibial traction³.Open callus osteoclasis, reduction, and condylar plating⁴.Sequestrectomy with preservation of a periosteal sleeve to treat osteomyelitis complicating an open fracture¹.Transfemoral amputation to treat gas gangrene or vascular injury following severe open injury^1,5-7.

Rationale

This procedure was developed in remote medical facilities where patients are often first seen >21 days after the original injury. By that time, closed reduction or standard open reduction and internal fixation techniques are no longer possible. After 6 months of fracture age, the procedure is inefficient.

Expected Outcomes

This procedure allows correction of limb malalignment and shortening while preserving the growth plate¹.

Important Tips

In some cases, hypertrophic fracture callus might be mistaken for the femoral diaphysis.An extensive musculoperiosteal release will facilitate reduction of the fracture fragments.The adequacy of reduction must be assessed in all 3 planes intraoperatively.The adequacy of reduction must be assessed in all 3 planes intraoperatively.The adequacy of reduction must be assessed in all 3 planes intraoperatively.

Malunited and malrotated Salter-Harris type I fracture of distal femur managed with circular ring external Ilizarov fixator

A 9-year-old girl presented with malunited Salter-Harris type I fracture of distal femur treated by bone-setter (unreliable-practitioner). Assessment revealed 3 cm limb-length-discrepancy and affected leg was unable to bear weight, knee was stiff with no active-range of motion; radiographs showed displaced sagittally malunited femoral condyle with 163° posterior distal femoral angle (PDFA). Correction planned with circular-ring-external Ilizarov fixator using distraction-osteogenesis through supracondylar osteotomy and gradual anterior opening. Partial weight bearing allowed from first postoperative day on walker. Eight weeks follow-up showed restored anatomical position of femoral condyle and PDFA. During anterior-distraction and angulation correction, tibia subluxated posteriorly, for that assembly extended to tibia which gradually translated tibia anteriorly and reduced knee. Twenty weeks after removal of assembly patient was advised knee-ankle-foot-orthosis. At 40 weeks of frame removal, patient was walking without support and pain. Managing such rare injuries with distraction-osteogenesis technique allows gradual correction and monitoring, till desirable degree of correction is achieved.