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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 24  |  Issue : 3  |  Page : 107-109

Management of a pediatric subtrochanteric fracture: A conventional technique using an unconventional implant


1 Department of Orthopaedics, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
2 Department of Orthopaedics, CHAF, Bengaluru, Karnataka, India
3 Department of Orthopaedics, CH(EC), Kolkata, India

Date of Submission29-Dec-2020
Date of Decision09-Mar-2021
Date of Acceptance31-Mar-2021
Date of Web Publication01-Apr-2022

Correspondence Address:
Surg Cdr (Dr) Mohammed Schezan Iqbal
Department of Orthopaedics, INHS Kalyani, Visakhapatnam - 530 005, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_197_20

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  Abstract 


Pediatric subtrochanteric fractures have been treated historically with intramedullary nailing, sliding hip screw, or pediatric proximal femoral locking plates, which are often based on the fracture pattern or availability of suitable implants. It is desirable to use a technique of fixation that will not only restore the hip biomechanics but also be a stable construct. We present a conventional technique of reduction and fixation of a subtrochanteric femoral fracture in an 8-year-old child using an unconventional implant, namely an adult proximal humerus locking plate, with a successful outcome and no postoperative complications.

Keywords: Adult proximal humerus locking plate, pediatric hip trauma, subtrochanteric fracture femur


How to cite this article:
Iqbal MS, Kulsreshtha V, Harikrishnan B, Singh V B. Management of a pediatric subtrochanteric fracture: A conventional technique using an unconventional implant. J Mar Med Soc 2022;24, Suppl S1:107-9

How to cite this URL:
Iqbal MS, Kulsreshtha V, Harikrishnan B, Singh V B. Management of a pediatric subtrochanteric fracture: A conventional technique using an unconventional implant. J Mar Med Soc [serial online] 2022 [cited 2022 Aug 9];24, Suppl S1:107-9. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/3/107/342381




  Introduction Top


Pediatric subtrochanteric femoral fractures are a rare occurrence (4%–10% of all pediatric femoral fractures).[1] Different treatment options to manage these fractures include skin or skeletal traction, hip spica casting, and internal or external fixation. Treatment options are affected by the child's age, associated injuries, economic constraints,[2] and availability of appropriate implants. In this report, we have described the use of a nonconventional implant to fix pediatric subtrochanteric fracture during the COVID-19 pandemic.


  Case Report Top


An 8-year-old female presented to our center on May 11, 2020, with pain in the left hip and inability to bear weight following a motor vehicle accident. On examination, she had a flexion, abduction, and external rotation deformity of the left hip with 1 cm limb shortening. She was unable to perform straight leg raise with marked tenderness in the groin. The hip movements were painful and restricted. There were no neurovascular deficits in the affected extremity. Plain radiograph of the pelvis [Figure 1] showed a displaced subtrochanteric fracture of the left femur in varus malalignment (31-M/3.1 III as per Orthopaedic Trauma Association classification). In view of the fracture pattern, a decision to perform open reduction and internal fixation using an angle stable construct was made. Due to ongoing COVID-19 pandemic, no pediatric hip locking plate was available in our city, and an alternative implant (adult proximal humerus locking plate [PHLP]) was used to minimize time to surgery.
Figure 1: X Ray Pelvis with Both Hips AP view (Pre-operative)

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Surgical technique

Under general anesthesia, the patient was placed supine on a radiolucent table. An attempt was made at indirect reduction of the fracture which was failed and a direct reduction was performed through lateral approach to proximal femur. Reduction was achieved using clamps and provisionally stabilized using 1.5-mm Kirschner wires. An anteversion wire was placed first in the step toward definitive fixation. A 3.5-mm ipsilateral adult PHLP was applied laterally, and four 2.0-mm guide wires were passed high into the femoral neck through the screw-in guides attached to the proximal flare of the plate. The satisfactory position of the plate and guide wires was confirmed fluoroscopically in anteroposterior and frog-leg lateral views. The screw lengths were measured using a direct measuring device over the wire on the locking guide. A 2.7-mm cannulated drill bit was used over the guide wires to drill holes, and 3.5-mm locking screws of appropriate lengths were applied one at a time. The shaft fragment was controlled using a loosely applied bone-plate clamp, and final fixation to the plate was done using four 3.5-mm locking screws, with care being taken not to overtighten the clamp and lose the reduction. Definitive fluoroscopic images were obtained of an acceptable reduction and fixation, and wound was closed. Hip range of motion exercises was started on the 1st postoperative day, and she was advised nonweight-bearing ambulation with support for 6 weeks. We did not experience any postoperative complications. Postoperative plain radiograph at 3-month follow-up is shown in [Figure 2]. The hip range of motion achieved at 3-month follow-up was 110° of hip flexion, 30° of hip extension, 45° abduction, 40° adduction, 80° of external rotation, and 60° of internal rotation [clinical photographs shown in [Figure 3]a and [Figure 3]b.
Figure 2: X Ray Pelvis with Both Hips AP view (Post-operative at 3 month follow-up)

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Figure 3: (a) and 3 (b): Clinical photographs of the patient at 3 month follow-up

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  Discussion Top


Pediatric proximal femur fractures are infrequent, with subtrochanteric fractures being still rarer. These fractures result from high-energy trauma, with associated multisystem injuries.[3] The management of subtrochanteric fractures is based on fracture geometry and age of the patient. Theologis and Cole[4] suggested traction and application of hip spica in patients <10 years of age and operative intervention only if the alignment was not acceptable. However, of late, there has been increasing use of operative procedures in these fractures, owing to the fact that successful surgery can result in early restoration of hip range of motion, accurate fracture reduction, quicker mobilization, and prevention of complications associated with hip spica. This was described by Jarvis et al.[5] in their study comparing operative versus conservative management of pediatric subtrochanteric fractures, in which they concluded that operative treatment provided more satisfactory results than conservative measures. Different options are available for open reduction and internal fixation of pediatric subtrochanteric fractures, each having its own indication. Titanium elastic nail (TEN) is the implant of choice when the fracture is undisplaced and early mobilization is required. However, associated problems with this system include occasional limb-length discrepancy and possible rotation of the distal fragment. Lateral plating using proximal femoral locking plate (PFLP) (open/submuscular) is preferred over TEN in difficult, displaced, or comminuted fractures as it provides an angle stable construct with the possibility of accurate reduction of the fracture fragments, maintaining alignment, and length. Li et al.[6] concluded that plate fixation leads to better outcome scores and lesser rate of complication as compared to TEN.

Planning for our case, we came across different unconventional plate options for the fixation of this fracture in literature. Sanders and Egol[7] proposed that a distal tibial locking plate in a young child and a proximal tibial locking plate in an adolescent conformed well to the contour of the proximal femur and were a practical alternative to conventional PFLP. Gogna et al.[8] performed a case series using adult PHLP for the management of pediatric subtrochanteric fractures and concluded that PHLP of the ipsilateral side was a good treatment option for the age group of 10–16 years.

We decided to use the adult PHLP primarily because in the present COVID-19 pandemic, there was no availability of a pediatric PFLP, and the fracture pattern was not amenable to a TEN fixation. We had a stock of adult PHLP readily available at our center, and we were successful in obtaining the desired reduction and fixation using this implant. Our technique was both anatomically and biologically successful. We were able to insert two rows of screws in the femoral neck, providing appropriate stability which is not possible with dynamic compression or modified reconstruction plates. Based upon our experience, we recommend this technique in the setting of nonavailability of pediatric PFLP for the management of pediatric subtrochanteric fractures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Segal LS. Custom 95 degree condylar blade plate for pediatric subtrochanteric femur fractures. Orthopedics 2000;23:103-7.  Back to cited text no. 1
    
2.
El-Sayed M, Abulsaad M, El-Hadidi M, El-Adl W, El-Batouty M. Reconstruction plate fixation of subtrochanteric femoral fractures in children. Acta Orthop Belg 2007;73:484-90.  Back to cited text no. 2
    
3.
Mirdad T. Fractures of the neck of femur in children: An experience at the Aseer Central Hospital, Abha, Saudi Arabia. Injury 2002;33:823-7.  Back to cited text no. 3
    
4.
Theologis TN, Cole WG. Management of subtrochanteric fractures of the femur in children. J Pediatr Orthop 1998;18:22-5.  Back to cited text no. 4
    
5.
Jarvis J, Davidson D, Letts M. Management of subtrochanteric fractures in skeletally immature adolescents. J Trauma Acute Care Surg 2006;60:613-9.  Back to cited text no. 5
    
6.
Li Y, Heyworth BE, Glotzbecker M, Seeley M, Suppan CA, Gagnier J, et al. Comparison of titanium elastic nail and plate fixation of pediatric subtrochanteric femur fractures. J Pediatr Orthop 2013;33:232-8.  Back to cited text no. 6
    
7.
Sanders S, Egol KA. Adult periarticular locking plates for the treatment of pediatric and adolescent subtrochanteric hip fractures. Bull NYU Hosp Jt Dis 2009;67:370-3.  Back to cited text no. 7
    
8.
Gogna P, Mohindra M, Verma S, Thora A, Tiwari A, Singla R. Adult proximal humerus locking plate for fixation of paediatric subtrochanteric fractures. Musculoskelet Surg 2014;98:189-94.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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