Authors of section

Authors

Arnold Besselaar, Daniel Green, Andrew Howard

Executive Editor

James Hunter

General Editor

Fergal Monsell

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Complications and technical failures

1. Introduction

Femoral fractures are often high-energy injuries and are associated with significant but predictable complications including limb-threatening vascular injuries.

Growth-plate injury is common following distal femoral fractures and early diagnosis is important to avoid progressive malalignment.

2. Vascular injuries

The popliteal vessels are at risk of injury with distal femoral and proximal tibial fractures.

This is particularly relevant in the presence of significant displacement because the neurovascular bundle is fixed at the soleal arch.

Arterial injuries include transection, major branch avulsion and intimal tears. Limb ischemia may occur immediately following injury or develop in the subsequent hours or days.

Compartment syndrome can develop after partial or temporary ischemia.

Diagnosis:

  • High index of suspicion with displaced fractures
  • Record foot pulses, skin color and temperature
  • Examine distal muscle groups for stretch pain and worsening pain out of proportion with the injury
  • Measure ankle brachial index
  • Consider doppler ultrasound, angiogram, or CT angiogram but do not delay reduction of fracture

Treatment:

  • Urgent fracture reduction and stabilization
  • Collaborate with a surgeon capable of vessel exploration and repair
  • Consider prepping the contralateral limb for vein graft
  • Consider prophylactic fasciotomy if the ischemic time exceeds 6 hours
Neurovascular structures in the popliteal fossa
Case 1

The x-ray shows significant anterior displacement and shortening of a Salter-Harris II fracture in a 6-year-old female. The patient had a pulseless white foot and a complete transection of the popliteal vessels.

X-ray of a Salter-Harris II with significant anterior displacement and shortening

X-ray of the healed fracture after removal of K-wires. Vascular clips show the location of the open vessel repair.

X-ray of a healed fracture with vascular clips
Case 2

Angiogram following proximal tibial growth plate injury shows partial occlusion of the popliteal artery. The narrowed vessel on the angiogram corresponds to tearing of the vessel intima.

Clotting resulted in complete occlusion of the vessel two days later.

Angiogram following proximal tibial growth plate injury showing partial occlusion of the popliteal artery

3. Growth-plate injuries

Injury to the growth plate is common after all patterns of distal femoral fracture.

All patients should be followed to demonstrate that growth has resumed or to ensure early diagnosis of growth-plate injury.

Recommended reading:

In this case the x-ray shows complete Harris lines in the metaphysis.

They are parallel to the growth plate indicating normal growth.

X-ray showing complete Harris lines in the metaphysis

Anatomy of distal femoral growth plate

The growth plate of the distal femur has multiple undulations in both coronal and sagittal planes. The epiphysis and metaphysis interdigitate and this resists shearing forces.

Clinical consequences:

  • Higher energy to cause growth-plate disruption
  • Fracture may cross all zones of the growth plate
  • Growth plate injury occurs in up to 50% of patients
Anatomy of distal femoral growth plate

Complete closure of distal growth plate

A fracture pattern with a large transverse disruption of the growth plate is more likely to cause a uniform growth arrest.

In this case a partial reduction of a Salter-Harris II fracture with a small medial metaphyseal fragment is seen.

X-ray of a partially reduced Salter-Harris II fracture with a small medial metaphyseal fragment

Anatomic reduction of the fracture has been performed and smooth K-wires used for stabilization to minimize secondary damage to the growth plate.

Anatomic reduction and fixation with smooth K-wires

At 12 weeks the affected left distal femoral physis is completely closed. The contralateral side has a wide-open growth plate.

Note the horizontal sclerotic Harris line showing proximal tibial growth on the left side since the fracture.

Unequal closing of the distal femoral physis

Options for ensuring leg length equality at maturity include epiphysiodesis of the opposite side (illustrated) or surgical lengthening of the affected leg.

Epiphysiodesis of the opposite side

Partial closure of distal growth plate

Case 1

This 9-year-old boy was a pedestrian struck by a motor vehicle. He sustained a displaced Salter-Harris II fracture of the distal femur.

The lateral growth plate is completely disrupted but the medial growth plate is protected by the large metaphyseal (Thurstan Holland) fragment.

X-ray of a displaced Salter-Harris II fracture

The fracture has been stabilized with metaphyseal cannulated screws and protected in a cast.

The patient is at high risk of partial or complete growth plate closure and should be followed closely until growth is proven to resume.

X-ray of a Salter-Harris II fracture stabilized with metaphyseal cannulated screws and protected in a cast

He missed two years of follow-up.

There is significant valgus deformity due to ongoing growth of the medial side of the growth plate but cessation on the lateral side.

Earlier diagnosis would mean less deformity and more straightforward treatment.

Significant valgus deformity due to cessation on the lateral side

Standing x-ray shows significant shortening and deformity.

Standing x-ray showing significant shortening and deformity

Treatment included gradual deformity correction with leg lengthening and completion of epiphysiodesis on the medial side.

Standing x-ray showing gradual deformity correction with leg lengthening and completion of epiphysiodesis on the medial side
Case 2

This 5-year-old female has incomplete reduction of a Salter-Harris II fracture stabilized with K-wires. The gap visible centrally in the physis may permit bony ingrowth and bar formation.

Immediate postoperative films also demonstrate varus angulation.

The medial side of the growth plate has its metaphyseal portion attached and is relatively protected.

X-ray showing an incomplete reduction of a Salter-Harris II fracture stabilized with K-wires

At 12 weeks the irregularity in the lateral half of the growth plate suggests early bony bar formation.

X-ray showing irregularity in the lateral half of the growth plate suggesting early bony bar formation

Closer inspection shows growth lines converging toward the site of the early bar. But the finding at this time is subtle and the diagnosis was not made.

Closer inspection showing growth lines converging toward the site of the early bar

MRI imaging allows the growth plate to be directly visualized and demonstrates a physeal bar.

MRI imaging visualizing the growth plate and demonstrating a physeal bar

Later CT imaging confirms an anterolateral bony bar which has produced a valgus and substantial extension deformity.

CT imaging confirming an anterolateral bony bar resulting in a valgus and substantial extension deformity

Clinically the knee hyperextended by 30° and the valgus deformity was evident.

X-ray showing valgus deformity of the knee

Osteotomy was used to correct the deformity. Length inequality will be addressed in a later procedure.

Earlier diagnosis of the bar may have resulted in less deformity and simplified treatment eg, bar excision or completion of epiphysiodesis.

Anatomic reduction may have prevented formation of this bar. However, some bars will form even after anatomic reduction due to the injury to the germinal layer.

X-ray of an osteotomy correcting the valgus deformity

4. Angular deformity following incomplete reduction

Experimental physeal disruption

Gomes and Volpon investigated the evolution of physeal bars after Salter-Harris IV injuries, at a histological level.

Salter-Harris IV fracture

They demonstrated that if the transphyseal fracture plane was not surgically closed and stabilized, vessels invaded the fracture plane, forming a bony tether across the physis. This led to a locus of growth arrest.

Clinical implication: Anatomical reduction of physeal injuries should reduce the risk of growth arrest.

Vascular invasion into the fracture plane of a Salter-Harris IV injury
Vascular invasion into the fracture plane of a Salter-Harris IV injury