FEMORAL NECK FRACTURE IN A YOUNG PATIENT

The Case for August 2012 is of a 35 year old male who sustained a fracture to his hip during a motorcycle accident.  He sustained a displaced femoral neck fracture.  He was seen by the trauma team and was cleared for operative intervention for his fracture once other injuries had been ruled out.

The fracture had both medial and posterior superior comminution.  There was a retroversion deformity on the lateral view.  This injury carries with it a significant risk of developing avascular necrosis of the femoral head which can lead to early arthritis and disability.  Fracture union can also be problematic as there are significant shear forces across the fracture during healing.

Anatomic reduction in a timely manner is key to maintaining blood flow to the femoral head and allowing for the best chance of fracture healing.  The patient was brought to the operating room when cleared for an open reduction of his fracture.  This was accomplished through a Smith-Peterson anterior approach allowing for direct visualization of the fracture.  With this approach we were able to clean the fracture, clamp it on the anterior tension side to restore anteversion, and restore anatomic alignment under direct visualization.  Also, the hip capsule was incised allowing for decompression of the joint to hopefully improve blood flow to the head.

The fracture reduction was held with a clamp and wire and then guide wires for 7.0 mm cannulated screws were placed through a separate small lateral incision.  We avoided the posterior superior neck region with our fixation so we would not further compromise blood flow to the femoral head.  A screw was placed inferiorly abutting the neck and then two further screws were placed more superiorly with good spread.  Partially threaded screws were used to allow for fracture compression.

Final intraoperative plain films showed an excellent reduction.

The patient was allowed to perform toe-touch weightbearing for three months.  He then progressed to full weight bearing as tolerated.  Serial radiographs were taken throughout his follow-up at six weeks and three months showing no loss of reduction. 

The patient was seen 9 months following surgery.  He walked with a normal gait, had no hip pain, and had returned to all vocational and avocational activities.  Although the patient is still at risk of developing avascular necrosis in the future, radiographs showed a healed fracture with no evidence of avascular necrosis of the femoral head at last follow-up.

A femoral neck fracture in a young patient is a serious injury as it can lead to pain and arthritis secondary to avascular necrosis.  Anatomic reduction with secure fixation contributes to a successful outcome.

Author by Daphne M. Beingessner, MD

Adolescent Supracondylar Humerus Fracture – should it be treated as a pediatric or adult injury?

The Case of the Month for June 2012 is of a 12 year old healthy young lady who sustained a displaced supracondylar humerus fracture after a fall from a balance board. She presented with a completely displaced distal humerus fracture, similar in appearance to a pediatric Type III supracondylar humerus injury. She had mild paresthesias in her thumb but otherwise had an unremarkable neurovascular examination. Her injury radiographs are shown below:

Of note, her distal humerus growth plate was closed but she still had a partially open olecranon growth plate and radial head growth plate.

This fracture represents a very unstable pattern. Given the patient’s age and the fact that her growth plates were nearly closed, it was felt that she would be better treated with a plate construct that would allow for early range of motion. Also, at age 12, she does not have much, if any, potential to remodel so an accurate and anatomic reduction is imperative to restore elbow function. Therefore, an adult approach to this fracture was felt to be appropriate.

The patient was taken to the operating room within 24 hours of her injury. She was placed in the lateral position and a paratricipital (triceps-sparing) approach to the distal humerus was performed. The ulnar nerve was identified but not transposed. A significant amount of force was required to reduce the fracture and it was held provisionally with Kirschner wires.

It was clear that the Kirschner wires would not have been adequate fixation (as would be used in a younger child) as the fracture deformed once the clamp was removed. A posterior plate was chosen of sufficient thickness to help reduce the residual extension deformity, to buttress the articular segment and prevent it from going back into the extended position it was in at the time of injury.

A second plate was added medially for extra stability and the construct was stable through a full range of motion.

The arm was placed into a padded splint for 48 hours to allow the incision to seal and then active and active assisted motion was started. The majority of motion was regained by 6 weeks. At three months, the fracture was completely healed and the patient had regained full range of motion. At final follow-up at six months, she had returned to all activities including dance and gymnastics with no pain and no limitations.

This patient had an excellent result with her injury. This fracture pattern in adolescents should not be confused with a pediatric supracondylar fracture that is readily treated with percutaneous pinning and a cast for 3 to 4 weeks. Intraoperatively, it was clear in this case that wire fixation would have been inadequate since multiple wires were not sufficient to maintain the reduction, even provisionally. In adolescents, stiffness and loss of fixation and subsequent malunion may occur with percutaneous fixation and an adult approach is appropriate.

Author by Daphne M. Beingessner, MD

Femur fracture nonunion with leg length discrepancy: a treatment strategy for difficult post-traumatic problem. *Updated with New Images

This month’s case features a 40-year old healthy man who, unfortunately, was struck by a vehicle 13 months earlier.  He sustained a closed femoral shaft fracture in the distal metadiaphyseal region.  He was treated at an outside facility with open reduction of the fracture followed by antegrade trochanteric nailing.  Suboptimal placement of the initial distal interlocking bolts was not appreciated until 5 weeks postoperatively, at which time the bolts were revised and placed accurately through the distal interlocking holes in the nail.  

Approximately one year from the date of his injury, he presented to Harborview Medical Center for an opinion regarding his ongoing pain and limitations.  His complaints include significant weightbearing and activity-related pain located to the distal thigh and anterior knee area.  While this pain was a predominant symptom, his most frustrating problem was the perception that his left leg was shorter than his right.  He is otherwise healthy and was previously an avid athlete, particularly involved in long distance running and bicycle riding.  He is a nonsmoker, and takes no medications on a regular schedule.  He has been unable to wean himself off of a walking aid because of continuing lower thigh discomfort and the inability to correct his “limp”.  He has been unable to participate in any of his running or bicycling activities.  The physical examination demonstrates well-healed surgical scars at the left hip and distal thigh regions.  The quadriceps musculature of the left thigh is atrophic.  Clinically, there is an approximate 2cm leg length discrepancy with the left leg shorter than the right.  There are no significant rotational abnormalities.  The passive hip and knee ranges of motion are symmetric to the contralateral side.  The pedal pulses were palpable, and the patient’s motor and sensory examination was normal, within the limitations of pain.  Initial bloodwork demonstrated a number of normal values, including the white cell blood count, ESR, C-reactive protein, and bone metabolism profile.

The presenting anteroposterior plain radiographs of the left femur demonstrate a well-aligned hypertrophic metadiaphyseal nonunion.  A trochanteric antegrade femoral nail is identified, and the single distal interlocking bolt is noted to be broken.  The long leg standing radiographs confirm an approximate 2cm leg length discrepancy with the left femur shorter than the right.  The operative records from the index procedure confirm the size, length, and manufacturer of the medullary implant, and also indicate that the femur fracture was reduced using an open technique prior to the placement of the nail.

The diagnosis is a well aligned, but clinically shortened, hypertrophic, aseptic distal metadiaphyseal femoral nonunion. 

The patient was extensively counseled regarding the options regarding the treatment of this problem.  Typically, the well vascularized hypertrophic nonunion develops because of fracture site instability.  Enhancing the stability of the fracture/nonunion site with a traditional compression plating technique typically results in predictable and rapid healing of the nonunion site.  Unfortunately, this strategy, by itself, does not correct the significant and clinically bothersome leg length discrepancy.  Alternatives include contralateral shortening osteotomy of the femur to equalize leg lengths, ipsilateral oblique osteotomies to regain length while still compressing the nonunion, or lengthening through the nonunion, either acutely or gradually.  Each of these options comes with risks related to healing and increased surgical complexity.  Given the patient’s desire to restore his anatomy as accurately as possible, we decided to treat this problem with acute lengthening through the nonunion site followed by stabilization with a locked reamed medullary nail with plate augmentation.   

The patient was medically stable and cleared for surgery.  A general anesthetic was administered and he was positioned supine on a radiolucent operating table.  The patient was supported with a soft left-sided lumbo-sacral support.  The entire left lower extremity was then included in the sterile operating field, and the preoperative patient/procedure verification was completed.  Antibiotic prophylaxis was withheld until deep cultures of the nonunion site were obtained.
The patient’s pre-existing trochanteric femoral nail was removed percutaneously.  Through the same skin incision, a piriformis fossa start point was obtained and an entry hole created into the proximal femur in the appropriate trajectory.  A curved ball-tipped guide wire was then placed down the femur, across the nonunion site and into the distal femur beyond the endpoint of the previously placed nail.  The canal was enlarged with sequential reaming to a total of 13mm.  The anticipated nail length was estimated using a two-guide rod technique taking into consideration the additional 2 cm of femoral lengthening.  Multiple specimens of fibrous tissue and reamings from the endosteal surface of the femur were sent for culture and sensitivity.  Subsequent to this, prophylactic antibiotics were administered.
The curved ball-tip guide rod was then retracted into the proximal femoral segment and the nonunion was then approached with a lateral extensile exposure to the femur.  After elevation of the vastus lateralis, the nonunion itself was exposed using an osteo-periosteal technique as described by Judet and Judet.  Two 2.4mm Steinmann pins were placed into the anterolateral surface of the femur on either side of the nonunion.  The distance between these two pins was measured and recorded.  Peripheral to these pins, two bicortical 5mm Schanz pins were placed and attached to a large Universal Distractor.

The nonunion site was mobilized then distracted 2cm and confirmed accurate by repeat measurement using the 2.4mm Steinmann pins.

The nonunion site was then stabilized with a posterolateral locking plate using screws strategically placed to be out of the way of the anticipated nail pathway.

The 2.4mm Steinmann pins, the 5mm Schanz pins, and the Universal Distractor were then removed.  A straight insertion rod was then placed through the piriformis fossa nail entry point and positioned into the distal femur, followed by the definitive statically locked medullary nail.  A portion of the anterior and anterolateral aspects of the hypertrophic nonunion were removed with an osteotome, morselized and reinserted into the nonunion gap created by the lengthening.  The wounds were then closed and final clinical and radiographic assessments in the operating room demonstrated symmetric leg lengths, angulation, and rotation.

The patient had an uneventful postoperative recovery course and the intraoperative specimens sent for microbiologic examination demonstrated no growth of organisms at the two week mark.  Six weeks postoperatively, he was progressed to from touchdown to full weightbearing.  He had no pain and full knee range of motion.  Twelve weeks postoperatively strengthening exercises  were initiated and the patient was weaned from his walking aids.  Two months later, the patient began light jogging and workouts with a stationary bicycle.  Approximately one year postoperatively, the patient has no pain and is back to his recreational activiities, including completion of the “Escape From Alcatraz” triathlon.

Authored By: David P. Barei.,M.D

Minimally Invasive Manipulative Reduction and Fixation of Pelvic (Pubic & Sacral) Fractures

This month's case features a 19 years old male who was injured in a high-speed automobile accident. He was the driver of the vehicle and medics at the scene noted significant intrusion of the driver’s side of the car. He was extracted from the vehicle, complained of pelvic and back pain. On presentation to the emergency department, he was awake and alert, and continued to complain of severe left sided low back and hip area pain. He was initially hemodynamically unstable but responded to routine volume resuscitation. His physical examination revealed left pelvic and back pain with any attempted passive movement. Compressive pelvic exam identified pelvic mechanical instability and related exacerbation of his complaints. There was no pelvic deformity or abnormal other findings. The lower extremity neurological and vascular examinations were within normal limits, excepting muscle power limitations due to pain.

Plain pelvic radiographs and a computed tomography scan demonstrated displaced left sided pubic ramus and sacral fractures. The axial CT images demonstrated the fracture and deformity details. The left hemipelvis was flexed and internally rotated relative to the uninjured right side.  The patient was fully resuscitated and evaluated. He and his parents were counseled regarding the various non-operative and operative treatment options, as well as the risks and benefits of each. They opted for attempted manipulative reduction and percutaneous fixation if possible, and agreed to open reduction and internal fixation if needed.

On the day after injury, the patient was medically stable and cleared for surgery. He was anesthetized, positioned supine on the radiolucent operating table, elevated on a soft lumbo-sacral support, and the entire abdomen and bilateral flanks were included in the sterile operating field. After the preoperative patient/procedure verification was completed and antibiotic prophylaxis administered, a simple 2 pin anterior oblique pelvic external fixation device was applied using bilateral 5mm pins inserted into the right iliac crest and left supra-acetabular areas. The single bar oblique frame was oriented to correct the left hemipelvic flexion and internal rotation deformities. The compression-distraction device was applied to the bar remote from the injured areas so to not obstruct pelvic fluoroscopic imaging.  The manipulative reduction was assessed using fluoroscopy until satisfactory ramus and sacral re-alignment reductions were achieved.  Then antegrade superior pubic ramus medullary screw and iliosacral screw fixations were placed percutaneously through small stab wounds under multiplanar fluoroscopic guidance. The postoperative imaging confirmed the reduction accuracy, deformity correction, and screw safety. On the day after surgery, he was comfortable and began his rehabilitation including weight of limb protected weight bearing using crutches, and isometric exercises for the subsequent 6 weeks. He returned for follow up evaluation with no complaints, radiographic union of his fractures, and was released to his normal activities 3 months after injury.

Authored By: M.L. Chip Routt, Jr.,M.D