Percutaneous bridging of pediatric femoral fractures deemed ‘an effective technique’

SAN FRANCISCO — Using percutaneous bridging plates for pediatric femoral fractures proved to be a reliable, uncomplicated alternative to flexible nails for Clifford B. Jones, MD, and his colleagues at a Level 1 trauma center in Grand Rapids, Mich.

Jones recently reported results using the technique from 2002 to 2006 to treat 78 fractures. Although callus formation began a little later than with femoral nailing, 91% of fractures healed by 6- to 12-weeks postoperative and patients usually walked into the office at the 2-week follow-up, he said.

“Bridge plating is an effective technique, especially if done in a submuscular fashion with longer plates and less screws. Kids have a rapid time to healing and discharge from the hospital once this is performed,” Jones said at the American Academy of Orthopaedic Surgeons 75th Annual Meeting.

No traction

In reviewing results of the level 4, retrospective cohort study, Jones described the surgical technique he and his co-investigators used, saying they placed patients on a radiolucent table but did not put them in traction. They made a small skin incision and inserted the plate submuscularly, basing the plate’s entry point, either proximal or distal, on where the fracture pattern originated.

“A more retrograde position of the plate requires it to be more distal, while a more antegrade insertion requires it to be more proximal to replicate the anatomy of the femur,” Jones explained.

Investigators placed sutures around the cortical screws to help them when they later needed to remove the screws. They typically used a combination of locking and standard screws.

Short vs. long plates

Jones and colleagues studied the technique in two groups of patients, ages 4 to 12 years old and 13 to 16 years old (average age, 9 years). He said there were more males overall, particularly among the older group of patients. The males’ fracture patterns were also more reflective of motor vehicle accidents.

Patients were typically treated the day of injury or the next day. Healing was assessed 2, 6 and 12 weeks later.

The length of hospital stay was brief. “They went through the hospital system quite quickly. The average length of stay for isolated injuries was about 3 days. Of course, polytrauma patients had a longer time in the hospital than those with isolated fracture patterns,” Jones noted.

They typically used 10- or 12-hole 3.5 dual compression plates (DCPs) in the younger patients and 14- to 16-hole 4.5 DCPs in older ones.

Healed at 6 to 12 weeks

Most patients healed by 6 to 12 weeks. Younger patients healed a little faster than the older ones, but any healing differences between the age groups were not significant, he said.

“Complications were uncommon, with the highest one being leg length discrepancy, which occurred five times,” Jones said. “The leg length discrepancy was less than 12 mm in these cases.”

According to the literature, submuscular bridge-type plating is gaining in popularity. “The usual description was a longer plate, fewer screws, indirect reduction methods, bridging early callus healing,” Jones explained. Published results in the pediatric population showed the technique is safe for complex fractures. It mitigates shortening problems and can be used without bracing, he noted.

During the discussion period Jones said none of the patients in the study re-fractured after their plates were removed.

Once he removed the patients’ plates, Jones allowed them to resume sports activities whenever they felt comfortable doing so, but about 10% of patients did not want their plates removed, he noted.

Because he believes poor limb alignment remains a major downside of fixing pediatric femoral fractures with flexible nailing, Jones now plates about 97% of them. They are typically ones involving metaphyseal extension comminution, bone loss, unstable fracture patterns or noncompliance issues, like traumatic brain injuries, he told Orthopedics Today.

For more information:
Clifford B. Jones, MD, can be reached at Orthopaedic Associates of Grand Rapids, 230 Michigan St. NE, Suite 300, Grand Rapids, MI 49503-2550; 616-459-7101; e-mail: cbjones@oagr.com. He receives research and other support from and is a consultant to Zimmer, he received research support from Medtronic and he received miscellaneous support from AO, although support was not provided for this study.

Reference:
Jones CB, Tressel W, Sietsema D, et al. Percutaneous bridge plating for pediatric femoral fractures. Paper #430. Presented at the American Academy of Orthopaedic Surgeons 75th Annual Meeting. March 5-9, 2008. San Francisco.