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Name:
Paediatric Femoral Fractures for FRCS
Description:
Paediatric Femoral Fractures for FRCS
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T00H21M11S
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https://cadmoreoriginalmedia.blob.core.windows.net/dec3e73e-8d22-414a-8751-94ece6cff543/Paediatric Femoral Fractures for FRCS.mp4?sv=2019-02-02&sr=c&sig=5%2BBLYZqSojM3AS61yeibdq7G6%2Fa44g1nQuBM9eKhTYY%3D&st=2024-11-24T19%3A48%3A03Z&se=2024-11-24T21%3A53%3A03Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
This actual presentation is not entirely my presentation. This presentation has been given in Edinburgh symposium from a symposium by Mr Aleister Murray, and I have to give him the credit. I'm just sharing with you guys about what is up to date.
This is the presentation this year and last August last month. OK, so to start with. So femur fracture in children, it can be addressed by different ways, can be addressed operatively, like with public cornice, with the balance traction with the speaker can be also addressed surgically.
As we can see over here, we have names, we have rejuvenates flexible names and please don't say tense, just say either very flexible names or intermediary names. And we have plates, of course, and we have extensive procedures. So as you can see, we have many, many different modalities and there is no right and wrong. So in pediatric, usually you need to use your common sense, you have the tools and how you're going to use it in the best way for the best outcome.
So just quick, epidemiology is 1 in 5,000 kids, or maybe less, it depends. You can think about how many you see new hospital. Overall, it is 2% of kids fractures. It is more common in men and it has by modern age distribution, so it is more in toddlers. And then it goes down and then become more around 10 years or so when teenager kicks in.
The non-accidental injury is bad and fail, so if any kids under one-year-old actually under three years old, you should think about it. But specifically on the one year old, it is unforgivable not to mention it. So if you saw a female fracture, a humera fracture, you have to say humerus is the most common and femur fracture is the second most common.
If a child came with a minor trauma, with the structure of his femur, what we should think about. Other non-accidental injury. It is pathological structure. So we need to examine or investigate more and maybe to liaise with the pediatrician about this. Maybe there is a metabolic or genetic disorder in this child. So quickly, we will go through the age groups, and this is what you need to know.
You don't need to know anything else. It is direct. It is a simple and well known question. So again, less than two years old, then I would think non-accidental injury again, don't forget. And then the child is still very young or six, maybe up to six months. I'll use publicness if it is more than this I can use.
And this can be earlier delayed. When I would it is, of course, it is the preference, but the recommendation, decision, preference, I mean, but the recommendation is if there is more than 2 to 3 centimeters overlapping, then it is advisable to get traction first and then put you speaker. If it is just less than this, you can put the speaker directly.
Why the two centimeters. Because we are expecting at this age group that will be an overgrowth anyway of 2 to 3 centimeters. So this will be compensated for, but we have to always warn or advise appearance about this shortening at the beginning and then this will be compensated for and in case, it's less than two centimeters. We advise them on the other side that there would be about there is overgrowth, but this will be equalized while the child is growing on.
And of course, at the end, the attraction or the balance holds brain structure, ok? The next if it is a little bit older, 2 to five years. OK, so. I this will take out of the equation, the public. So we have the speaker and we have the balanced action, so instruction. Traction then spoke with a media spike and usually three to five weeks duration are enough.
People have different preferences in applying the speaker. As we said, one of them is it early or after some traction and the other preference? Should we do 1 and 1/2 or should we do both? But the most important is just to try to bend the knee a little bit so they can. The parent can carry the child. And don't forget about the hygiene in the Pyrenees.
So these are some examples over here, so we can see if on the right side, that was a fracture. And it's well here, it's well, the remodeling process took place and we can see on the other side, there's another one with traction. So the first one is just directly they applied the plaster. The second one, they put attraction for a week or so, and then they applied their plaster or hip spike.
So next, we are coming now to more challenging area. So it's 6 to 12 years old, so it is a distraction protection and speicher the child starting to get a little bit heavier. The weight is increasing. And that will put him at risk of skin problems. So there's a 10% skin problems and there is 7% malnutrition, including excess shortening, as per the paper in 2018.
OK should we think about surgery? What is the best surgery? Our options over here would be either flexible kneeling, plating an ex fix. If you noticed we didn't mention over here the solid kneeling because this child is still growing, they are. Still, we are concerned about the blood supply and we don't need. We don't want to interfere either with growth or the developing skeleton.
If I would put it that way, so flexor-pronator, there are some tricks about it. And there are some drawbacks. So it needs some considerations. It needs some experience. But generally speaking, it is. It depends on fixation. So you go from one side to the cortex to the other cortex, and the nails should be crossing, filling at least 2/3 of the medullary diameter.
And the best is to get this crossing at the site of the fracture. So is it easy? Not many people find it easy. Personally, I find it very easy and it's a very, very good operation. But I know that many people there try to avoid it if you put some results. We have.
Some 25% of skin irritation, which is a very, very high risk like one in four, 10% you need to open, but usually it is a very small, many open reduction and this, you can actually just do it, reduce it and then you pass, you bring the nail at the fractured side and then you just reduce the fracture and pass the needle in. There will be 3% on infection like anything else, 10% LeBlanc discrepancy more than one central and 10% more.
If you're putting your nail with that will cause destruction of the fracture site, which is something strange to happen in children age group. But this is more common, of course, as you may know, with many open reduction. Is it always work? Not always. There are some problems.
If it is commuted, if it is very high. Is a child, has high BMI or if they are not compliant with non bearing or partial weight bearing instructions. So it can happen like this. But as we can see, still adhered to can see good colors, formation and hopefully this will remodel, but it can be worse than this.
Again, be careful about. Well, the fracture is the fracture in the distant femur or femur, the middle as white and then it cannot really control it. Flexor-pronator, as I told you before, it is the best is to get the crossing at the fracture site. So you can have these huge stresses. But if it is that low, you cannot. Although I would say the best indication for the nail is mid shaft and transverse fracture.
So you need to think when you are planning to do a flexible kneeling, so you need to select your patient carefully. You need to have some experience because there are many small tricks, although it is easy or there are many small tricks as even as a solid nailing in adults it is. Some people find it very difficult.
Some people find it the it is their favorite so type of fracture in the community. It is transverse. It is. Is it long? Oblique is butterfly the nail size, the best way to just to get the diameter on the lateral x-ray? And then you put, if the diameter say. Uh, I would say if centimeters then put 10mm nailed two of them, so that's two thirds, if it is 1 centimeter, then he will use 3 millimeter and 3 and millimeter actually will not be enough.
We said at least Jets. So it will be four. And the best is to be the same diameter. Both names length of the bone. Make sure that the bone is not longer than your flexo-pronator. Although this is not common, you'll need a fracture table, but it depends. Some people don't do.
Some people do. And finally, the weight of the patient, the recommendation is the patient should be less than 50 kilograms. And I would say, put your upper limit is 45 kg, so 45 to 50 kilograms in the upper limit to use flexor-pronator. Next is plating the next option. So in plating, it is always this is what we know. This is what we learned at the beginning of our training.
We all do plating. So this is a valid option, but in children is a little bit tricky. Should we? It is a scar. It is a violation of the muscles. Should we remove it or should we not? A lot of this, but sometimes we have to use it, unfortunately. So it is the best SLAP muscular breaching locking plates and this can be done under fluoroscopy.
And this is the best indication for plating when you cannot need so either flexible naming or rigid kneeling, you cannot kneel for some reasons, then it is the best to use plating, usually multiple injuries. Sometimes you need something quick. Something will not put the patient on and a lot of stresses on their systems, especially the lungs, so multiple injuries using plate can be the solution.
Or if there is compliance issues against nails, especially flexible nails or costs so that the child has maybe some mental problems, the parents are not reliable enough. So you can always use plate and just go to sleep. So still, we have complication 4% per plate fracture as this paper and overgrowth may be a problem with this. And no problem.
There are problems like if there is nonunion, if there's too much stripping or if there is metabolic disorders, then this can happen. So again, be careful. Last resort fast, soft tissue injury. If there is soft tissue injury, open fracture, trauma, all this. So this is the best solution at the beginning, at least even in the adult. Put your x fix, stabilize the patient and then decide what you go.
What you're going to do. It is, you know, that's the rule of Spence can plan. But they found that there is a very highly fractured rate up to 10% to 20% and there is 75% pain infection. So this is very, very high. So think carefully before you decide the next fix and has to be justified. Otherwise we would be in trouble. Now, the very debatable issue logged criminal.
So all of the issue is that even. And there is a 5% risk as per studies and in the last person that they reported that the got only 14 cases in 1600s names. If you reach this stage, you can be asked easily about the plot supply of the femoral head in children. So this is a must know.
I must know, must know, unforgiveable question if you don't know it. Some question in this exam, the knowledge is difficult. They know it's not basic and they can forgive you for it. But this question is really an important one. And you can feel if you didn't answer it or you are not straightforward with it. So there are some studies about the relation between the avian risk and the entry point.
So McNeil he published in 2011 and they found that performance for entry point is 2% risk tip of the greater Hunter 1.4 percent, but the lateral entry is 0% So it's very clear message that always use the lateral entry nailing four in pediatric age group. And even now, to more or less, we are using an adult spot in pediatric is we have.
These are more studies if you are aiming for eight. You can always go code this. So either you can say there are three. Remember, this is a most recent one and we all know miller, so you can say the 17 cases now, even with little internet in 2012. In summary.
Infant child abuse less than three years. Child abuse. I will think about it. Less than one year, I would actually. Look for it. I will ask and ask and ask, I will not let it go like this. A child who is not walking, it's very difficult to get a picture of him, so always remember this, and when he asks you, what are you going to do for this?
This is an x-ray, blah blah blah blah blah. My concern here is and I first answer and then the next question of what are you going to do for this? I will do. I have these options. It depends on the child weight because I'm concerned also about if there is any skin problems with the traction construction or if very, very young.
It is like months I put public honest and I'll put spyker and then take him and the spyker. I will look at the over lab overlapping. If it is more than three centuries I would prefer to put a short period of traction, maybe up to week and then apply my spyker. Otherwise, I'll apply my spyker directly. And then he will tell you, OK, next.
So if this is how the question goes, OK, what if this X-ray is for a child that's six years old? What are you going to do? So my my, my preferred options will be nailing flexo-pronator unless there is a condor integration for this or their problem and spitting in this child. So he told you like what you can say, like if it is more than 50 kilograms or if there is, there is a concern about the compliance.
So what is your other options? So the other options? Six years old. Still, I can put spyker I or I can plate. OK And then. So we say over here in the summer, if the length unstable flexo-pronator, if the length unstable or proximal fracture.
Yeah, don't forget this. Then it is musker plate or rigid lateral into. It's a little bit older. Fix, fix, protect, will bearing after removal because there is a very high risk of fracture. Up to 20% in regional avoid reforms phosa or turbo flexor-pronator for a reason is because we know this 2% and 1.4 percent, respectively, and always want the parents about the leg length and prolonged limp.
These are the two most comprehensive people you can always quote at the end. It is. This is common in library. It is intervention for treating premature fraction children and adolescents. And this is, of course, a British one and the American one. It is the iOS guidelines.
Thank
Segment:0 .
This actual presentation is not entirely my presentation. This presentation has been given in Edinburgh symposium from a symposium by Mr Aleister Murray, and I have to give him the credit. I'm just sharing with you guys about what is up to date.
This is the presentation this year and last August last month. OK, so to start with. So femur fracture in children, it can be addressed by different ways, can be addressed operatively, like with public cornice, with the balance traction with the speaker can be also addressed surgically.
As we can see over here, we have names, we have rejuvenates flexible names and please don't say tense, just say either very flexible names or intermediary names. And we have plates, of course, and we have extensive procedures. So as you can see, we have many, many different modalities and there is no right and wrong. So in pediatric, usually you need to use your common sense, you have the tools and how you're going to use it in the best way for the best outcome.
So just quick, epidemiology is 1 in 5,000 kids, or maybe less, it depends. You can think about how many you see new hospital. Overall, it is 2% of kids fractures. It is more common in men and it has by modern age distribution, so it is more in toddlers. And then it goes down and then become more around 10 years or so when teenager kicks in.
The non-accidental injury is bad and fail, so if any kids under one-year-old actually under three years old, you should think about it. But specifically on the one year old, it is unforgivable not to mention it. So if you saw a female fracture, a humera fracture, you have to say humerus is the most common and femur fracture is the second most common.
If a child came with a minor trauma, with the structure of his femur, what we should think about. Other non-accidental injury. It is pathological structure. So we need to examine or investigate more and maybe to liaise with the pediatrician about this. Maybe there is a metabolic or genetic disorder in this child. So quickly, we will go through the age groups, and this is what you need to know.
You don't need to know anything else. It is direct. It is a simple and well known question. So again, less than two years old, then I would think non-accidental injury again, don't forget. And then the child is still very young or six, maybe up to six months. I'll use publicness if it is more than this I can use.
And this can be earlier delayed. When I would it is, of course, it is the preference, but the recommendation, decision, preference, I mean, but the recommendation is if there is more than 2 to 3 centimeters overlapping, then it is advisable to get traction first and then put you speaker. If it is just less than this, you can put the speaker directly.
Why the two centimeters. Because we are expecting at this age group that will be an overgrowth anyway of 2 to 3 centimeters. So this will be compensated for, but we have to always warn or advise appearance about this shortening at the beginning and then this will be compensated for and in case, it's less than two centimeters. We advise them on the other side that there would be about there is overgrowth, but this will be equalized while the child is growing on.
And of course, at the end, the attraction or the balance holds brain structure, ok? The next if it is a little bit older, 2 to five years. OK, so. I this will take out of the equation, the public. So we have the speaker and we have the balanced action, so instruction. Traction then spoke with a media spike and usually three to five weeks duration are enough.
People have different preferences in applying the speaker. As we said, one of them is it early or after some traction and the other preference? Should we do 1 and 1/2 or should we do both? But the most important is just to try to bend the knee a little bit so they can. The parent can carry the child. And don't forget about the hygiene in the Pyrenees.
So these are some examples over here, so we can see if on the right side, that was a fracture. And it's well here, it's well, the remodeling process took place and we can see on the other side, there's another one with traction. So the first one is just directly they applied the plaster. The second one, they put attraction for a week or so, and then they applied their plaster or hip spike.
So next, we are coming now to more challenging area. So it's 6 to 12 years old, so it is a distraction protection and speicher the child starting to get a little bit heavier. The weight is increasing. And that will put him at risk of skin problems. So there's a 10% skin problems and there is 7% malnutrition, including excess shortening, as per the paper in 2018.
OK should we think about surgery? What is the best surgery? Our options over here would be either flexible kneeling, plating an ex fix. If you noticed we didn't mention over here the solid kneeling because this child is still growing, they are. Still, we are concerned about the blood supply and we don't need. We don't want to interfere either with growth or the developing skeleton.
If I would put it that way, so flexor-pronator, there are some tricks about it. And there are some drawbacks. So it needs some considerations. It needs some experience. But generally speaking, it is. It depends on fixation. So you go from one side to the cortex to the other cortex, and the nails should be crossing, filling at least 2/3 of the medullary diameter.
And the best is to get this crossing at the site of the fracture. So is it easy? Not many people find it easy. Personally, I find it very easy and it's a very, very good operation. But I know that many people there try to avoid it if you put some results. We have.
Some 25% of skin irritation, which is a very, very high risk like one in four, 10% you need to open, but usually it is a very small, many open reduction and this, you can actually just do it, reduce it and then you pass, you bring the nail at the fractured side and then you just reduce the fracture and pass the needle in. There will be 3% on infection like anything else, 10% LeBlanc discrepancy more than one central and 10% more.
If you're putting your nail with that will cause destruction of the fracture site, which is something strange to happen in children age group. But this is more common, of course, as you may know, with many open reduction. Is it always work? Not always. There are some problems.
If it is commuted, if it is very high. Is a child, has high BMI or if they are not compliant with non bearing or partial weight bearing instructions. So it can happen like this. But as we can see, still adhered to can see good colors, formation and hopefully this will remodel, but it can be worse than this.
Again, be careful about. Well, the fracture is the fracture in the distant femur or femur, the middle as white and then it cannot really control it. Flexor-pronator, as I told you before, it is the best is to get the crossing at the fracture site. So you can have these huge stresses. But if it is that low, you cannot. Although I would say the best indication for the nail is mid shaft and transverse fracture.
So you need to think when you are planning to do a flexible kneeling, so you need to select your patient carefully. You need to have some experience because there are many small tricks, although it is easy or there are many small tricks as even as a solid nailing in adults it is. Some people find it very difficult.
Some people find it the it is their favorite so type of fracture in the community. It is transverse. It is. Is it long? Oblique is butterfly the nail size, the best way to just to get the diameter on the lateral x-ray? And then you put, if the diameter say. Uh, I would say if centimeters then put 10mm nailed two of them, so that's two thirds, if it is 1 centimeter, then he will use 3 millimeter and 3 and millimeter actually will not be enough.
We said at least Jets. So it will be four. And the best is to be the same diameter. Both names length of the bone. Make sure that the bone is not longer than your flexo-pronator. Although this is not common, you'll need a fracture table, but it depends. Some people don't do.
Some people do. And finally, the weight of the patient, the recommendation is the patient should be less than 50 kilograms. And I would say, put your upper limit is 45 kg, so 45 to 50 kilograms in the upper limit to use flexor-pronator. Next is plating the next option. So in plating, it is always this is what we know. This is what we learned at the beginning of our training.
We all do plating. So this is a valid option, but in children is a little bit tricky. Should we? It is a scar. It is a violation of the muscles. Should we remove it or should we not? A lot of this, but sometimes we have to use it, unfortunately. So it is the best SLAP muscular breaching locking plates and this can be done under fluoroscopy.
And this is the best indication for plating when you cannot need so either flexible naming or rigid kneeling, you cannot kneel for some reasons, then it is the best to use plating, usually multiple injuries. Sometimes you need something quick. Something will not put the patient on and a lot of stresses on their systems, especially the lungs, so multiple injuries using plate can be the solution.
Or if there is compliance issues against nails, especially flexible nails or costs so that the child has maybe some mental problems, the parents are not reliable enough. So you can always use plate and just go to sleep. So still, we have complication 4% per plate fracture as this paper and overgrowth may be a problem with this. And no problem.
There are problems like if there is nonunion, if there's too much stripping or if there is metabolic disorders, then this can happen. So again, be careful. Last resort fast, soft tissue injury. If there is soft tissue injury, open fracture, trauma, all this. So this is the best solution at the beginning, at least even in the adult. Put your x fix, stabilize the patient and then decide what you go.
What you're going to do. It is, you know, that's the rule of Spence can plan. But they found that there is a very highly fractured rate up to 10% to 20% and there is 75% pain infection. So this is very, very high. So think carefully before you decide the next fix and has to be justified. Otherwise we would be in trouble. Now, the very debatable issue logged criminal.
So all of the issue is that even. And there is a 5% risk as per studies and in the last person that they reported that the got only 14 cases in 1600s names. If you reach this stage, you can be asked easily about the plot supply of the femoral head in children. So this is a must know.
I must know, must know, unforgiveable question if you don't know it. Some question in this exam, the knowledge is difficult. They know it's not basic and they can forgive you for it. But this question is really an important one. And you can feel if you didn't answer it or you are not straightforward with it. So there are some studies about the relation between the avian risk and the entry point.
So McNeil he published in 2011 and they found that performance for entry point is 2% risk tip of the greater Hunter 1.4 percent, but the lateral entry is 0% So it's very clear message that always use the lateral entry nailing four in pediatric age group. And even now, to more or less, we are using an adult spot in pediatric is we have.
These are more studies if you are aiming for eight. You can always go code this. So either you can say there are three. Remember, this is a most recent one and we all know miller, so you can say the 17 cases now, even with little internet in 2012. In summary.
Infant child abuse less than three years. Child abuse. I will think about it. Less than one year, I would actually. Look for it. I will ask and ask and ask, I will not let it go like this. A child who is not walking, it's very difficult to get a picture of him, so always remember this, and when he asks you, what are you going to do for this?
This is an x-ray, blah blah blah blah blah. My concern here is and I first answer and then the next question of what are you going to do for this? I will do. I have these options. It depends on the child weight because I'm concerned also about if there is any skin problems with the traction construction or if very, very young.
It is like months I put public honest and I'll put spyker and then take him and the spyker. I will look at the over lab overlapping. If it is more than three centuries I would prefer to put a short period of traction, maybe up to week and then apply my spyker. Otherwise, I'll apply my spyker directly. And then he will tell you, OK, next.
So if this is how the question goes, OK, what if this X-ray is for a child that's six years old? What are you going to do? So my my, my preferred options will be nailing flexo-pronator unless there is a condor integration for this or their problem and spitting in this child. So he told you like what you can say, like if it is more than 50 kilograms or if there is, there is a concern about the compliance.
So what is your other options? So the other options? Six years old. Still, I can put spyker I or I can plate. OK And then. So we say over here in the summer, if the length unstable flexo-pronator, if the length unstable or proximal fracture.
Yeah, don't forget this. Then it is musker plate or rigid lateral into. It's a little bit older. Fix, fix, protect, will bearing after removal because there is a very high risk of fracture. Up to 20% in regional avoid reforms phosa or turbo flexor-pronator for a reason is because we know this 2% and 1.4 percent, respectively, and always want the parents about the leg length and prolonged limp.
These are the two most comprehensive people you can always quote at the end. It is. This is common in library. It is intervention for treating premature fraction children and adolescents. And this is, of course, a British one and the American one. It is the iOS guidelines.
Thank
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