Open reduction; screw and K-wire fixation

A multifragmentary SH III fracture may require a combined approach using a screw to achieve anatomical reconstruction of the joint and K-wires for stabilization of the epiphysis to the metaphysis.

The main goals of treatment of these fractures are:

• Restore joint congruity
• Uncomplicated healing
• No secondary displacement
• Minimize injury to the growth plate

Distal femoral physeal fractures are associated with a high rate of growth arrest (30–50%). To minimize the risk, reduction should be anatomical and conducted with minimal force.

Most of these fractures are displaced and require open reduction to restore the articular surface while the screws for fixation may be placed open or percutaneously.

Reduction of these fractures can be approached through a medial or lateral parapatellar incision, depending on the fracture anatomy.

4.0–7.3 mm cannulated lag screws (ideally self-drilling, self-tapping) should be used.

The following equipment is needed:

• Full set for ORIF
• Cannulated screw set
• Drill
• Threaded guide wire
• Forceps for fracture reduction
• Image intensifier

Place the patient supine on a radiolucent table with a C-arm.

Perform a medial or lateral parapatellar arthrotomy to remove debris and allow direct visualization of the articular fracture.

Directly reduce the fracture and hold the fragment with forceps or a K-wire which also may serve as a joystick. Application of forceps or K-wire may require a separate stab incision.

Confirm anatomical reduction with image intensification.

Insert a K-wire in the epiphysis, parallel to the growth plate, to temporarily fix the fracture.

Confirm anatomical reduction with image intensification.

Perform a separate stab incision at the level of the planned screw insertion.

Spread the underlying soft tissues with a clamp and place a soft-tissue protector down to the bone.

Insert a guide wire in the epiphysis parallel to and away from the growth plate.

If the K-wire for temporary fixation is in an ideal position for the screw this can be used instead.

Determine the appropriate screw length.

Choose a partially threaded screw ensuring that the thread will not cross the fracture.

Insert the screw and compress the fracture.

Confirm anatomical reduction, fixation, and stability with image intensification.

Remove the temporary K-wire(s).

Gently reduce the growth plate under direct vision.

Extend the incision if there is a block to reduction (eg periosteum).

Insert smooth K-wires across the growth plate from the lateral and medial femoral condyles through separate stab incisions.

Check implant position and fracture reduction with image intensification.

Use clinical examination to check lower extremity alignment.

This construct usually requires protected weight bearing and knee immobilization with a molded long leg cast or brace for 3–6 weeks.

The patient should get out of bed and begin ambulation with crutches on the first postoperative day.

In most cases the postoperative protocol will be touch-weight bearing for the first 4 weeks.

Routine pain medication is prescribed for 3–5 days postoperatively.

The patient should be examined regularly, to exclude neurovascular compromise.

With displaced high-energy fractures watch for signs of delayed vascular problems.

Compartment syndrome, although rare, should be considered in the presence of severe swelling, increasing pain, and changes to neurovascular signs.

Discharge from hospital follows local practice and is usually possible after 1–3 days.

The patient should ambulate with crutches.

In stable fractures the knee is immobilized in a removable brace and range-of-motion exercises can begin early in the postoperative phase.

For the more unstable or comminuted fractures, range-of-motion exercises will begin after cast removal.

Clinical and radiological follow-up is usually undertaken 2 weeks postoperatively.

Physeal fractures heal quickly and cast and K-wires are typically removed 3–6 weeks postoperatively.

All patients with physeal fractures of the distal femur should have clinical and radiological examination 8–12 weeks postoperatively to assess for signs of physeal growth disturbance or resumption of growth.

Examination should be repeated at intervals until resumption of normal growth is documented. This can be seen as a horizontal growth line (Harris line) that is parallel to the entire physis on both AP and lateral views.

A growth line that converges towards the growth plate may be the earliest sign of growth arrest and should prompt investigation/treatment or referral as appropriate.

Clinical assessment of leg length and alignment is recommended at one-year.

Clinical assessment of leg length uses a tape measure from the ASIS to the medial malleolus.

If there is any concern about leg length discrepancy or malalignment, long leg x-rays are recommended.

Leg length is measured from the femoral head to the ankle joint.

If symptoms develop, screws can be removed once the fracture is completely healed, usually 6–12 months postoperatively.