Pre-operative Conference

Trauma 4 Service
Jafer Terrence Lim, M.D.
JF, a 7 year old, male, Filipino, Roman Catholic,
residing in Quezon province

Chief complaint:
Pain on the right thigh and left knee
of 1 day duration
 History of Present Illness
• 1 day PTC
– Patient was run over by a jeepney which was
not able to stop on time.

– Patient was brought to a local hospital in

Lucena where xrays and splinting were done
and was advised transfer to POC
 Physical Examination
• Conscious, coherent, slightly agitated, stretcher-borne, with
IV line and indwelling foley catheter. Splints were also noted
on bilateral lower extremity.
• BP- 90/60 PR 110 RR 18 T- afebrile
• (+) Pale palpebral conjuctiva, anicteric sclera
• Adynamic precordium, AB 5th LICS MCL, (-) murmurs
• Flat abdomen, (-) tenderness, NABS
• (+) tenderness and swelling of R thigh and tenderness on
left distal thigh, (+) multiple abrasions on bilateral upper
extremity and R lower extremity. No lacerations, avulsions,
open wound, pulses full and equal
 Review of Systems
• (-) cough • (-) abdominal pain
• (-) loss of consciousness • (-) hematuria
• (-) headache • (-) diarrhea
• (-) vomitting • (-) constipation
• (-) dizziness • (-) weakness
• (-) paresthesia
• Past medical history
– Unremarkable
• Family history
– unremarkable
• Personal/social history
– unremarkable
 At the ER
– Xrays
– CBC
Patient’s Xrays
• CBC results showed hemoglobin of 0.74 and
hematocrit of 24%
 Diagnosis
• Fracture, closed, complete, comminuted,
displaced, middle third, femur, right. AO/OTA
32-B1
• Fracture, closed, complete, displaced,
supracondylar, femur, left. AO/OTA 32-A2
 Plan
• CR pinning under image intensifier,
supracondylar femur, left.
• Minimally Invasive Plate Osteosynthesis
(MIPO), femur, right.
Distal Femur Fixation
Midshaft Fixation
 THANK YOU!!!
GOOD MORNING!!!
• All Types of Operative Treatment versus
Nonoperative Treatment
– Good to moderate evidence (Grade A to B) from 2 RCTs,
– 1 systematic review, 1 prospective cohort study, and 17
retrospective cohort studies.
– 8 Operative treatment reduces malunion rate (OR 0.54
[95% CI 0.36, 0.81]).
– 8 Operative treatment reduces total adverse events (OR
0.74 [95% CI 0.57, 0.97]).

Pediatric Femoral Fractures: A Systematic Review of 2422 Cases

Rudolf W. Poolman, MD,* Mininder S. Kocher, MD,† and Mohit Bhandari, MD*
Evidence-Based Orthopedic Trauma
• Submuscular bridge plating offers advantages of increased
stability, avoidance of pin tract infections, early mobility
without bracing, avoidance of the growth plates and
preservation of proximal femoral blood supply.
• Complications were infrequent and the authors concluded that
this technique offered adequate stability for early functional
treatment and healing of all pediatric femoral shaft fractures.
• For most patients, a 4.5-mm, narrow, low-contact dynamic
compression plate was used. By 12 weeks, bony union was
seen in all patients.

Advances in the surgical management of pediatric femoral shaft fractures

Marshall A. Kuremsky and Steven L. Frick
Current Opinion in Pediatrics 2007, 19:51–57
• Unstable, complex (multifragmentary) and
significantly displaced high energy shaft
fractures are treated operatively. Transverse or
short oblique shaft fractures in patients <12
years may be treated with elastic
intramedullary nails. Bridge plating will
provide better stability in complex fractures.

Current Concepts in Pediatric Femur Fracture Treatment

Enes Kanlic, MD; Miguel Cruz, MD
OrthoSuperSite , Pediatric Orthopedics, Dec. 1, 2007
• We recommend hardware removal after
complete fracture healing, usually in 6 to 12
months. Implants left in the growing child
could become buried deep inside of the bone,
or cause “periprosthetic” fractures and/or
eventually impede adult reconstruction.

Current Concepts in Pediatric Femur Fracture Treatment

Enes Kanlic, MD; Miguel Cruz, MD
OrthoSuperSite , Pediatric Orthopedics, Dec. 1, 2007
• Femoral fractures commonly are treated with
operative stabilization in children with
multiple injuries.
• The femur can be stabilized with smooth
Steinmann pins or cannulated screws,
depending on the amount of displacement
and the type of fracture.
Instructional Course Lectures, The American Academy of Orthopedic Surgeons
– Orthopaedic Treatment of Fractures of the Long Bones and Pelvis in
Children who have multiple injuries.
Vernon T. Tolo
J Bone Joint Surg Am. 2000; 82: 272-80
• Percutaneous crossed Steinmann pins are
useful to hold supracondylar distal femoral
fractures. This allows full extension of the
knee.
• These pins are left protruding through the skin
and are removed on an outpatient basis three
to four weeks after insertion.
Instructional Course Lectures, The American Academy of Orthopedic Surgeons
– Orthopaedic Treatment of Fractures of the Long Bones and Pelvis in
Children who have multiple injuries.
Vernon T. Tolo
J Bone Joint Surg Am. 2000; 82: 272-80
• Open reduction with AO plate fixation has been
shown to be successful in treating femoral fractures
in children who have multiple injuries.
• This is a particularly effective technique when there
is an injury of the femoral artery needing repair
adjacent to the fracture.
• A disadvantage of fixation with a plate is that a
second operative procedure is needed in order to
remove the plate.
Instructional Course Lectures, The American Academy of Orthopedic Surgeons –
Orthopaedic Treatment of Fractures of the Long Bones and Pelvis in Children
who have multiple injuries.
Vernon T. Tolo
J Bone Joint Surg Am. 2000; 82: 272-80
• The Rush-pin
supracondylar
technique offers
enough stability to
allow early knee motion
and has the advantages
of both open and closed
techniques in managing
this type of fracture of
the femur.

Rush-pin fixation of supracondylar and intercondylar fractures of the femur

KD Sholbourne and FR Brueckmannd, JBJS Am. 1982; 64-169