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