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Fractures of the femoral shaft in childhood
Volume I Number I
W E B E R : C H I L D H O O D F R A C T U R E S OF FEMORAL SHAFT
65
FRACTURES OF THE FEMORAL SHAFT IN C H I L D H O O D B. G. WEBER
Orthopaedic Department, Kantonsspital St. Gallen, Switzerland
A conservative traction method for femoral shaft fracture in children is recommended. Ninety-seven of 105 cases have been treated this way from 1961 to 1967. It is the only method we know which facilitates the diagnosis and correction of primary rotational deformity. The treatment scarcely carries any risk and the children's management is simple. FEMORAL shaft fractures in children behave differently from similar fractures in adults. The important points a r e : - 1. Early consolidation with considerable callus formation. 2. Increased rate of growth for 2 years. 3. Spontaneous but limited correction of axial deformity without corresponding rotational correction.
A
Boehler, 1957; Chigot and Est6ve, 1958; Dameron and Thomson, 1959; Ehalt, 1961). Two complications may occur in spite of perfect technique : - -
B
Fig. l.--Vertical traction for femoral shaft fracture. A, Hip- and knee-joints flexed to 90°. B, Traction
exerted by suspension : fracture side with Steinmann pin, opposite leg with adhesive plaster traction. Both legs lying parallel. Thighs equal abduction of 20°. 4. No Sudeck's dystrophy. The child's femoral shaft fracture very easily. For this reason conservative ment is generally recommended (Bryant, Russell, 1924; Blount, 1954; Hoke,
heals treat1876; 1954,
1. Ischaemic damage, which though rare is a very serious complication, is described in Bryant's suspension. 2. Rotational deformity may occur with any of the traditional methods. There is hardly any
66
INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY
mention in the literature about rotational deformity, nor has anyone measured this. INHERENT PROBLEMS Tibial fractures may be assessed by simple clinical comparison of the broken leg with the
Injury July 1969
therefore, the distal femoral segments are accessible for direct comparison, because the hip-joints and the proximal femora are surrounded with soft tissues. In contrast to tibial fractures the proximal fragment of a femoral shaft fracture is not amenable to rotational control.
Fig. 2.--Check radiograph for malrotation (see Fig. 1B). Vertical radiograph centred on symphysis, radiograph plate under buttocks. Measurement of the angles between femoral neck and lower horizontal edge of the film (=knee axis).
t
'~
Fig. 3.--Correction of primary rotation. The distal femoral fragment is twisted to achieve correction, using the leg as a lever arm. opposite side. Moreover any rotational deformity is obvious and easy to eliminate by inspection and palpation of knee- and ankle-joints on both sides. But these methods cannot be applied to fractures of the femur: only the knee-joint and only,
There is no advantage in trying to keep the patellae just pointing forwards throughout fracture healing. The proximal femoral fragment can rotate to hide a rotational deformity, which is only discovered after union, when the child is found to be turning his knee and foot inwards or outwards when walking. Vontobel, Genton, and Schmid (1961) are the only authors who describe the rotational deformity in detail: late follow-up after femoral shaft fractures in children treated by traditional methods showed rotational deformity of 30° or more. How harmful rotational deformities are is described in my paper ' Z u r Behandlung Kindlicher Femurschaftbriiche' (Weber, 1963): rotational deformity of femur and tibia lead to late arthrosis of the respective joints. PRINCIPLES OF WEBER'S VERTICAL TRACTION (1963) Fig. 1 shows the injured child lying on a special frame. Both knees and hips are flexed to 90°, the femora diverging by about 20°. The
Volume I Number I
WEBER" CHILDHOOD FRACTURES OF FEMORAL SHAFT
tibiae lie parallel to one another. The desired position with the buttocks hanging free is obtained by suspension from an overhead beam: Steinmann pin traction to the fractured femur is used and adhesive plaster traction to the other leg. Bandages are used to keep the legs parallel.
67
unequal angles are evidence of rotational deformity, which is measured by the difference between the angles of the femoral necks : - 1. A smaller angle on the fracture side shows that the proximal femoral fragment is internally rotated.
Fig. 4.--A, Simple anteroposterior projection at the time of fracture. B, The same projection at 4 weeks, after traction has been discontinued, showing restoration of length. C, Appearance at 8 months, showing full remodelling. D, The standard pelvic film showing the respective femoral angles. The difference of 3° is within normal limits and this film confirms that rotational deformity has been eliminated. Conventional radiographs show the femoral fracture, but give no information about rotation. Therefore additional pelvic radiograph films are taken as shown in Fig. 1 a. The femoral necks subtend a certain angle to the horizontal, which is comparable and measurable in degrees (Fig. 2). If these angles are equal it is proof that no malrotation has taken place, for the distal femora are well fixed in identical positions due to the tibiae being held parallel. On the other hand
2. A greater angle of the femoral neck shows that the proximal femoral fragment is externally rotated. Torsional deformity may easily be corrected before callus forms, generally by the fourth day following fracture (Fig. 3). The proximal femoral end is surrounded by the soft tissues and is not accessible to manipulation, but the distal femoral fragment can be twisted on its axis in order to obtain correction. For this axial rotation we use
68
INJURY: THE BRITISHJOURNALOF ACCIDENTSURGERY
the tibia as a lever arm: the leg on the tibial table can be moved medially or laterally depending on the required correction of the axis. Then the tibia is fixed in its new position on the tibial table. If a second radiograph of the pelvis still shows the original position of the femoral necks, the desired correction at the fracture site has taken place. The fracture then heals without mairotation, After union we repeat the radiographic examination once more. The pelvic radiograph as described above is taken, showing similar positions of the femoral necks if femoral rotation is absent (such a radiograph is one of the two standard projections described by Dunlap, Shands, Hollister, Gaul, and Streit (1953), Dunn, (1952), and Rippstein (1955), to determine the angles of the proximal femora). MATERIAL From 1961 to 1967, 105 femoral shaft fractures in children aged 2-14 years have been treated at the Orthopaedic Department (Kantonsspital St. Gallen, Switzerland). These fractures have mostly been treated by the vertical traction method on our special frame. In 8 cases some other treatment was used : - 1. In some children of less than 3 years of age with scarcely displaced spiral fractures we preferred a primary plaster spica. 2. In juveniles conservative treatment was attempted (Boehler, 1957; Russell, 1924). If accurate reduction was not obtainable, immediate internal fixation with a compression plate or intramedullary nail was undertaken. The first 28 cases treated by our vertical traction during the years 1961-1963 have been followed up at between 5 and 7 years after injury. These comprised 15 transverse fractures and 13 spiral fractures. Eighteen cases had a fracture in the middle third, 6 cases in the upper third, and 4 in the lower third of the femur. Traction lasted for an average of 33 days. Full weightbearing was allowed 45 days after fracture. RESULTS In 26 of 28 cases we find overgrowth of the injured leg of 1-5 cm. in spite of primary overlapping. Minor deformity of the axis is corrected,
Injury July 1969
especially varus deformity and backward angulation, while valgus deformity and forward angulation do not correct so well. Eighteen cases show malrotation of less than 10°. None of the remaining l0 cases shows rotational deformity of more than 18°. In other words no child at follow-up showed such a degree of rotational deformity of the femoral neck as could be expected to induce late arthrosis. DISCUSSION In contrast to the traditional treatment of childrens' femoral shaft fractures the vertical traction method described enables primary rotational deformity to be discovered and corrected. The method of treatment is simple and reliable and little special care is needed. The children accept this method happily (Fig. 4).
REFERENCES
BLOUNT, W. P. (1954), Fractures in Children. Baltimore: Williams & Wilkins.
BOEHLER, L. (1957), Technik der Knochenbruchbehandlung, 12.-13. Aufl. Vienna: Maudrich. BRYANT, T. 0876), The Practice of Surgery, vol. 2. London: Churchill. CHIGOT,P. L., and EST~VE, P. (1958), Traumatologie Infantile. Paris: Expansion Scientifique Franqaise. DAMERON, T. B., jun., and THoMsor4, H. A. (1959), • Femoral Shaft Fractures in Children ', J. Bone Jt Surg., 41A, 1201. DUNLAP,K., SHANDS,A. R., HOLL1STER,L. C., GAUL, J. S., and STREIT,H. A. (1953), ~A New Method for Determination of the Torsion of the Femur', Ibid., 35A, 289. DUNN, D. M. (1952), ' Anteversion of the Neck of the Femur. A Method of Management ', Ibid., 34A, 181. EHALT, W. (1961), Verletzungen bei Kindern und Jugendlichen. Stuttgart: Enke. HOKE, M. (1954), quoted by BLOUNT(1954). RIPPSTEIN, J. (1955), ' Z u r Bestimmung der Antetorsion des Schenkelhalses mittels zweier R~ntgenaufnahmen ', Z. Orthop., 86, 345. RUSSELL, R. H. (1924), ' Fractures of the Femur: a Clinical Study ', Br. J. Surg., 11, 491. VONTOBEL, V., GENTON,N., and SCHMID, R. (1961), 'Die Sp~tergebnisse der Kindlichen Dislozierten Femurschaftfraktur ', Heir. chir..4cta, 28, 655. WEBER, B. G. 0963), ' Z u r Behandlung Kindlicher Femurschaftbrfiche ', Arch. orthop. Unfallchir., 54, 713.
Requests for reprints should be addressed to:--B. G. Weber, Orthopaedic Department, Kantonsspital St. Gallen,Switzerland.
W E B E R : C H I L D H O O D F R A C T U R E S OF FEMORAL SHAFT
65
FRACTURES OF THE FEMORAL SHAFT IN C H I L D H O O D B. G. WEBER
Orthopaedic Department, Kantonsspital St. Gallen, Switzerland
A conservative traction method for femoral shaft fracture in children is recommended. Ninety-seven of 105 cases have been treated this way from 1961 to 1967. It is the only method we know which facilitates the diagnosis and correction of primary rotational deformity. The treatment scarcely carries any risk and the children's management is simple. FEMORAL shaft fractures in children behave differently from similar fractures in adults. The important points a r e : - 1. Early consolidation with considerable callus formation. 2. Increased rate of growth for 2 years. 3. Spontaneous but limited correction of axial deformity without corresponding rotational correction.
A
Boehler, 1957; Chigot and Est6ve, 1958; Dameron and Thomson, 1959; Ehalt, 1961). Two complications may occur in spite of perfect technique : - -
B
Fig. l.--Vertical traction for femoral shaft fracture. A, Hip- and knee-joints flexed to 90°. B, Traction
exerted by suspension : fracture side with Steinmann pin, opposite leg with adhesive plaster traction. Both legs lying parallel. Thighs equal abduction of 20°. 4. No Sudeck's dystrophy. The child's femoral shaft fracture very easily. For this reason conservative ment is generally recommended (Bryant, Russell, 1924; Blount, 1954; Hoke,
heals treat1876; 1954,
1. Ischaemic damage, which though rare is a very serious complication, is described in Bryant's suspension. 2. Rotational deformity may occur with any of the traditional methods. There is hardly any
66
INJURY: THE BRITISH JOURNAL OF ACCIDENT SURGERY
mention in the literature about rotational deformity, nor has anyone measured this. INHERENT PROBLEMS Tibial fractures may be assessed by simple clinical comparison of the broken leg with the
Injury July 1969
therefore, the distal femoral segments are accessible for direct comparison, because the hip-joints and the proximal femora are surrounded with soft tissues. In contrast to tibial fractures the proximal fragment of a femoral shaft fracture is not amenable to rotational control.
Fig. 2.--Check radiograph for malrotation (see Fig. 1B). Vertical radiograph centred on symphysis, radiograph plate under buttocks. Measurement of the angles between femoral neck and lower horizontal edge of the film (=knee axis).
t
'~
Fig. 3.--Correction of primary rotation. The distal femoral fragment is twisted to achieve correction, using the leg as a lever arm. opposite side. Moreover any rotational deformity is obvious and easy to eliminate by inspection and palpation of knee- and ankle-joints on both sides. But these methods cannot be applied to fractures of the femur: only the knee-joint and only,
There is no advantage in trying to keep the patellae just pointing forwards throughout fracture healing. The proximal femoral fragment can rotate to hide a rotational deformity, which is only discovered after union, when the child is found to be turning his knee and foot inwards or outwards when walking. Vontobel, Genton, and Schmid (1961) are the only authors who describe the rotational deformity in detail: late follow-up after femoral shaft fractures in children treated by traditional methods showed rotational deformity of 30° or more. How harmful rotational deformities are is described in my paper ' Z u r Behandlung Kindlicher Femurschaftbriiche' (Weber, 1963): rotational deformity of femur and tibia lead to late arthrosis of the respective joints. PRINCIPLES OF WEBER'S VERTICAL TRACTION (1963) Fig. 1 shows the injured child lying on a special frame. Both knees and hips are flexed to 90°, the femora diverging by about 20°. The
Volume I Number I
WEBER" CHILDHOOD FRACTURES OF FEMORAL SHAFT
tibiae lie parallel to one another. The desired position with the buttocks hanging free is obtained by suspension from an overhead beam: Steinmann pin traction to the fractured femur is used and adhesive plaster traction to the other leg. Bandages are used to keep the legs parallel.
67
unequal angles are evidence of rotational deformity, which is measured by the difference between the angles of the femoral necks : - 1. A smaller angle on the fracture side shows that the proximal femoral fragment is internally rotated.
Fig. 4.--A, Simple anteroposterior projection at the time of fracture. B, The same projection at 4 weeks, after traction has been discontinued, showing restoration of length. C, Appearance at 8 months, showing full remodelling. D, The standard pelvic film showing the respective femoral angles. The difference of 3° is within normal limits and this film confirms that rotational deformity has been eliminated. Conventional radiographs show the femoral fracture, but give no information about rotation. Therefore additional pelvic radiograph films are taken as shown in Fig. 1 a. The femoral necks subtend a certain angle to the horizontal, which is comparable and measurable in degrees (Fig. 2). If these angles are equal it is proof that no malrotation has taken place, for the distal femora are well fixed in identical positions due to the tibiae being held parallel. On the other hand
2. A greater angle of the femoral neck shows that the proximal femoral fragment is externally rotated. Torsional deformity may easily be corrected before callus forms, generally by the fourth day following fracture (Fig. 3). The proximal femoral end is surrounded by the soft tissues and is not accessible to manipulation, but the distal femoral fragment can be twisted on its axis in order to obtain correction. For this axial rotation we use
68
INJURY: THE BRITISHJOURNALOF ACCIDENTSURGERY
the tibia as a lever arm: the leg on the tibial table can be moved medially or laterally depending on the required correction of the axis. Then the tibia is fixed in its new position on the tibial table. If a second radiograph of the pelvis still shows the original position of the femoral necks, the desired correction at the fracture site has taken place. The fracture then heals without mairotation, After union we repeat the radiographic examination once more. The pelvic radiograph as described above is taken, showing similar positions of the femoral necks if femoral rotation is absent (such a radiograph is one of the two standard projections described by Dunlap, Shands, Hollister, Gaul, and Streit (1953), Dunn, (1952), and Rippstein (1955), to determine the angles of the proximal femora). MATERIAL From 1961 to 1967, 105 femoral shaft fractures in children aged 2-14 years have been treated at the Orthopaedic Department (Kantonsspital St. Gallen, Switzerland). These fractures have mostly been treated by the vertical traction method on our special frame. In 8 cases some other treatment was used : - 1. In some children of less than 3 years of age with scarcely displaced spiral fractures we preferred a primary plaster spica. 2. In juveniles conservative treatment was attempted (Boehler, 1957; Russell, 1924). If accurate reduction was not obtainable, immediate internal fixation with a compression plate or intramedullary nail was undertaken. The first 28 cases treated by our vertical traction during the years 1961-1963 have been followed up at between 5 and 7 years after injury. These comprised 15 transverse fractures and 13 spiral fractures. Eighteen cases had a fracture in the middle third, 6 cases in the upper third, and 4 in the lower third of the femur. Traction lasted for an average of 33 days. Full weightbearing was allowed 45 days after fracture. RESULTS In 26 of 28 cases we find overgrowth of the injured leg of 1-5 cm. in spite of primary overlapping. Minor deformity of the axis is corrected,
Injury July 1969
especially varus deformity and backward angulation, while valgus deformity and forward angulation do not correct so well. Eighteen cases show malrotation of less than 10°. None of the remaining l0 cases shows rotational deformity of more than 18°. In other words no child at follow-up showed such a degree of rotational deformity of the femoral neck as could be expected to induce late arthrosis. DISCUSSION In contrast to the traditional treatment of childrens' femoral shaft fractures the vertical traction method described enables primary rotational deformity to be discovered and corrected. The method of treatment is simple and reliable and little special care is needed. The children accept this method happily (Fig. 4).
REFERENCES
BLOUNT, W. P. (1954), Fractures in Children. Baltimore: Williams & Wilkins.
BOEHLER, L. (1957), Technik der Knochenbruchbehandlung, 12.-13. Aufl. Vienna: Maudrich. BRYANT, T. 0876), The Practice of Surgery, vol. 2. London: Churchill. CHIGOT,P. L., and EST~VE, P. (1958), Traumatologie Infantile. Paris: Expansion Scientifique Franqaise. DAMERON, T. B., jun., and THoMsor4, H. A. (1959), • Femoral Shaft Fractures in Children ', J. Bone Jt Surg., 41A, 1201. DUNLAP,K., SHANDS,A. R., HOLL1STER,L. C., GAUL, J. S., and STREIT,H. A. (1953), ~A New Method for Determination of the Torsion of the Femur', Ibid., 35A, 289. DUNN, D. M. (1952), ' Anteversion of the Neck of the Femur. A Method of Management ', Ibid., 34A, 181. EHALT, W. (1961), Verletzungen bei Kindern und Jugendlichen. Stuttgart: Enke. HOKE, M. (1954), quoted by BLOUNT(1954). RIPPSTEIN, J. (1955), ' Z u r Bestimmung der Antetorsion des Schenkelhalses mittels zweier R~ntgenaufnahmen ', Z. Orthop., 86, 345. RUSSELL, R. H. (1924), ' Fractures of the Femur: a Clinical Study ', Br. J. Surg., 11, 491. VONTOBEL, V., GENTON,N., and SCHMID, R. (1961), 'Die Sp~tergebnisse der Kindlichen Dislozierten Femurschaftfraktur ', Heir. chir..4cta, 28, 655. WEBER, B. G. 0963), ' Z u r Behandlung Kindlicher Femurschaftbrfiche ', Arch. orthop. Unfallchir., 54, 713.
Requests for reprints should be addressed to:--B. G. Weber, Orthopaedic Department, Kantonsspital St. Gallen,Switzerland.