Case Report

Pediatric Distal Femur Fixation by Proximal Humeral Plate

Amr Atef Abdelgawad, M.D. 1 Enes M. Kanlic, M.D., Ph.D. 1
Address for correspondence and reprint requests Amr Atef Abdelgawad, M.D., Department of Orthopedics, Texas Tech University Health Sciences Center, 4801 Alberta Avenue, El Paso, TX 79905 (e-mail: amratef@doctor.com).
1 Department of Orthopedics, Texas Tech University Health Sciences

Center, El Paso, Texas J Knee Surg

Abstract
Keywords

fracture distal femur pediatric children adolescent metaphyseal fracture proximal humeral plate knee internal xation

Supracondylar fractures of the femur account for 12% of femoral fractures in children.1 These fractures represent a challenge for the orthopedic surgeon especially when they occur in older children. For young children (less than 8 years old), they can usually be treated by closed reduction with percutaneous K-wire xation and cast augmentation.2 However, for bigger size children, K-wire xation with cast immobilization may not provide adequate stability. It has been suggest that locking plate can be used for internal xation of these fractures,3,4 however, regular locking plates will only allow minimal points of xation in the distal segment between the fracture and the distal femoral physis. In this article, we report two cases of metaphyseal fracture of the distal femur in older children who were treated with open reduction internal xation using proximal humeral locking plate. This xation technique provided rigid xation of the small distal fragment without encroachment over the distal femoral physis.

Case Reports
Case 1
A 12-year-old boy with motocross injury (dirt bike) had comminuted right distal femoral metaphyseal fracture.

The Technique Used

A straight lateral incision was done over the distal part of the femur. The vastus lateralis was retracted anteriorly. Direct reduction was obtained and preliminary xation was obtained using thick K wires across the fracture. Then the proximal humeral locking plate (Synthes, Paoli, PA) was applied to maintain the reduction with more rigid xation. First the plate was xed to the proximal part of the fracture using cortical screw which pulled the bone to the plate. An oval hole can be used rst which will allow the plate to have some movement in distal to proximal direction if needed. After that the plate was xed to the distal fragment using all locking screws. Cortical screws should not be used distally as

received July 29, 2011 accepted September 5, 2011

Copyright 2012 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.

DOI http://dx.doi.org/ 10.1055/s-0031-1299658. ISSN 1538-8506.

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Distal femoral metaphyseal fractures are common injuries in children. Multiple treatment options have been described for this type of injury. For older children with distal metaphyseal fracture, there is still no optimal method of xation. We propose that the commonly used proximal humeral plate can provide good method of xation for this fracture in adolescents. Two children (12 and 14 years old) with distal metaphyseal femoral fracture were treated with proximal humeral plate. We describe the surgical technique and postoperative management. The two children healed with good alignment and full range of motion of the knee. No external immobilization (other than knee immobilizer for the rst 2 weeks) was used. We concluded that proximal humeral plate can provide adequate xation for teenagers with distal femoral metaphyseal fracture. It is readily available; provide multiple options for screw xation in the distal part of the fracture and ts easily on the distal part of the femur proximal to the physis.

Pediatric Distal Femur Fixation by Proximal Humeral Plate

Abdelgawad, Kanlic

Figure 1 (A, B) Anteroposterior and lateral view of comminuted distal metaphyseal femoral fracture. (C, D) Intraoperative uoroscopy after open reduction internal xation (ORIF) using proximal humeral plate. A separate anterior distal fragment was xed with a screw outside the plate. Note that the screws in the distal fragment have different sagittal direction. (E, F) Functional result 4 months later.
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Pediatric Distal Femur Fixation by Proximal Humeral Plate

Abdelgawad, Kanlic

Figure 2 (A, B) Anteroposterior and lateral view of left distal metaphyseal femoral fracture. (C, D) AP and lateral view 2 months after ORIF using proximal humeral plate showing anatomical reduction and good bridging calus.

the plate is not perfectly tting on the bone and if cortical screws were used, it may result in displacement of the fracture. Great care should be taken to make sure that the most distal screws do not violate the distal physeal growth plate. Unicortical locking screws are usually used in the distal most holes with the length that will make them end before reaching the distal physis. Intraoperative uoroscopy is mandatory in these cases to ensure that the screws do not encroach over the distal physis. Knee immobilizer was used for comfort for 2 weeks. After that, knee range of movement was allowed. Patient was allowed to start weight bearing on the affected side after signs of union were seen in the radiograph (after 6 weeks). Full level of activity was obtained by 3 months after surgery (Fig. 1).

Case 2
A 14-year-old boy with wrestling injury had suffered from oblique distal metaphyseal femur fracture. Same approach, reduction and xation method as the previous case was done. Two months after fracture, patient was fully weight bearing with full range of movement of the knee (Fig. 2).

Discussion
Distal femoral metaphyseal fractures are relatively common injuries in children that occur as a result of high-energy trauma.1 Despite that, only very few articles had discussed treatment options for these fractures.3,57 Treatment options for this injury include traction, cast brace, external xation, percutaneous K-wire xation, open reduction and internal
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Pediatric Distal Femur Fixation by Proximal Humeral Plate

Abdelgawad, Kanlic

Figure 3 (A) Distal femur metaphyseal fracture (lateral view). (B) Treatment by locking plate extending to epiphysis. Note that the screws are intraepiphyseal but do not cross the physis. (C) After removal of the plate (both sides are of equal length and symmetrical alignment).

xation, and submuscular bridge plating. All these treatment options have their drawbacks especially for treating older age children.3,4,8 Traction in 90 degrees exion of the hip and knee had been described as a treatment method for this fracture. However, it requires prolonged hospitalization and frequent radiograph to assess the reduction. Also it is hard to assess the coronal alignment with exion of the knee.4 Casting and cast bracing will not provide adequate xation of the fracture (especially against varus collapse). Percutaneous K-wire xation (smooth wires crossing the physis) of the distal femur metaphyseal fracture is a good treatment modality for small children (usually those less than 8 years old), but for bigger size children (teenagers), it may not provide adequate stability.2 In addition, these K wire are intra-articular with possible spread of infection to the knee joint. All the above measures require external immobilization for a period of time which may lead to stiffness of the knee. External xation can be used to treat distal femoral metaphyseal fracture. External xators have disadvantage of refracture after frame removal. Pin tract infection is the most frequent adverse effects of external xators. In addition, external xators around the thigh are usually not well tolerated by obese kids.6 Internal xation is becoming more popular method of treatment of distal femur fracture by the orthopedic surgeons.4,7 The presence of short distance between the fracture and the distal femoral physis is the main anatomic obstacle to use compression plate (dynamic compression plate). In most cases, there will be only a room for one or two bicortical screws. This will not be enough xation for teenagers. The advent of locking plate allowed having more xation in some cases by adding one or two unicorical screws.7 Despite that, with highly
The Journal of Knee Surgery

comminuted distal femoral fractures that extends close to the distal femoral physis in adolescent, the use of straight locking plate may not provide adequate number of xation points. Some surgeons will extend the plate across the physis and insert screws in the epiphysis.7 This will require early (after few months) removal of the plate and can result in damage of the physis if the screws violate the physis (Fig. 3). The optimal solution for the distal femur metaphyseal fracture in adolescent will be a precontoured (for the shape of the distal femur) locking plate that has multiple holes in the distal part of the plate and will stop short of the distal femoral physis. For most orthopedic surgeons, this is not available. To the best of our knowledge, only one company has this kind of plate which its design allows inserting two screws at the distal end of the plate instead of one screw (only one extra screw) (OrthoPediatric, Warsaw, IN). For most trauma surgeons, they do not have an easy access to this type of plate. Lam et al recently published a case report of treatment of distal femoral fracture in 11-year-old boy by proximal tibial Less Invasive Stabilization System (LISS) plate.5 The adult proximal humeral precontoured locking plates has a shape that can easily t over the distal femur in the pediatric population (Fig. 4). This type of plate is readily available in the vast majority of trauma center. There are multiple options for screw positioning in the proximal part of the plate (which will be applied to the distal part of the bone). Depending on the level and comminution of the fracture, usually there will be ve or six screws in the proximal part of the plate that will be used to x the distal part of the femur. In addition, these screws have different direction (divergent, convergent, and straight) which will allow for better xation. The proximal humeral plate ts easily (though not perfectly)

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Pediatric Distal Femur Fixation by Proximal Humeral Plate

Abdelgawad, Kanlic

Figure 4 (A, B) Saw bone model for pediatric femur with proximal humeral plate applied to it showing the good seating of the plate over the bone.

on the shape of the lateral distal metaphyseal part of the femur above the physis. It should be noted that the locking plate do not have to fully seat on the bone because it acts as internal xator. Surgeon should not use cortical screws in the distal part of the fracture to allow the plate to work as internal xator and not displace the fracture. We think the proximal humeral plate is better option than the LISS tibial plate described by Lam et al5 as it is less bulky, have more screw holes that can be used to x the distal fragment and its screws have different projections. Another advantage of proximal humeral plate over LISS plate is that the proximal humeral plate have both locking and regular screw holes and this allows the surgeon to use regular cortical screws in the proximal part of the bone to x the plate to the bone (LISS plate have only locking screw holes). One possible disadvantage of using this plate is that it uses 3.5 mm screws which in some cases (especially with obese teenagers) may not be strong enough to allow immediate weight bearing.

available, has multiple options for screws positions, and it easily ts over the distal femur part proximal to the distal physis.

References
1 Smith NC, Parker D, McNicol D. Supracondylar fractures of the

femur in children. J Pediatr Orthop 2001;21(5):600603

2 Butcher CC, Hoffman EB. Supracondylar fractures of the femur in

Conclusion
We recommend using the proximal humeral plate for distal metaphyseal femoral fractures in adolescents. Use of the proximal humeral locking plate for this type of fracture will provide many advantages to the orthopedic trauma surgeon. It is readily

children: closed reduction and percutaneous pinning of displaced fractures. J Pediatr Orthop 2005;25(2):145148 Beaty JH, Kasser JR. Femoral shaft fractures. In: Beaty JH, Kasser JR, eds. Rockwood & Wilkins Fractures in Children. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009 Zionts LE. Fractures and dislocations about the knee. In: Green NE, Swiontkowski MF, eds. Skeletal Trauma in Children. 4th ed. Philadelphia, PA: Elsevier; 2008 Lam HY, Lo CK, Cheung KY. The use of tibial Less Invasive Stabilization System (LISS) plate [AO-ASIF] for the treatment of paediatric supracondylar fracture of femur: a case report. J Orthop Surg 2010;5:10 Sabharwal S. Role of Ilizarov external xator in the management of proximal/distal metadiaphyseal pediatric femur fractures. J Orthop Trauma 2005;19(8):563569 Kanlic EM, Anglen JO, Smith DG, Morgan SJ, Pesntez RF. Advantages of submuscular bridge plating for complex pediatric femur fractures. Clin Orthop Relat Res 2004;426(426):244251 McCollough NC III, Vinsant JE Jr, Sarmiento A. Functional fracturebracing of long-bone fractures of the lower extremity in children. J Bone Joint Surg Am 1978;60(3):314319

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