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Management of Complex Situation with Ilizarov.
Case Report | Volume 4 | Issue 3 | JOCR July-Sep 2014 | Page 56-58 | Parekh HP, Dwidmuthe SC, Patil SD, Sonar S. DOI: 10.13107/jocr.2250-0685.198
Authors: Parekh HP[1], Dwidmuthe SC[2], Patil SD[3], Sonar S[4]
[1] Department. of Orthopaedics, Smt. Kashibai Navale Meical college and General Hospital, S.No. 49/1, Narhe , Pune – 411 041. India.
[2] NKP SIMS & LMH, Digdoh Hills Nagpur. India.
[3]Chief consultant orthopaedics surgeon, Noble Hospital, Hadapsar, Pune. India.
[4] Consultant Orthopaedic Surgeon, Nagpur. India.
Address of Correspondence:
Dr. Hemant Parekh, Department. of Orthopaedics, Smt. Kashibai Navale Meical college and General Hospital, S.No. 49/1, Narhe , Pune – 411 041. India. E-mail- dr_hemantparekh@yahoo.com
Abstract
Introduction: The treatment of tibia bone loss can be challenging. The surgical options for the treatment of bone loss include bone transport, vascularized fibula graft, and induced membrane.
Case Report: We present a case of complex compound fracture of tibia with bone loss. Interestingly patient sustained this injury in spite of having intramedullary nail in tibia which was inserted to stabilize previous fracture 9 months prior to trauma. The proximal half of the nail was protruding out of the wound at the time of presentation in emergency department. The nail was removed and stabilized with external fixator after wound closure. The bone gap and nonunion at fracture site was managed with Ilizarov fixator. At the end of treatment patient got satisfactory functional outcome.
Conclusion: Ilizarov method is a biologic and comprehensive method for management of bone loss, non union and limb length discrepancy.
Keywords: Fracture tibia, bone loss, Ilizarov, distraction osteogenesis.
Introduction
Hip fractures are very common in adults, but are rare in children, comprising less than 1% of all pediatric fractures [1, 2]. The proximal femur in children, except for the proximal femoral epiphysis, is extremely strong and high-energy forces, such as from motor vehicle accidents and high falls, are necessary to cause fracture [1]. Pediatric hip fractures generally are classified by the method of Delbet because its simplicity and uniformity allow accurate description and reporting of results of each fracture by type [3]. Type I is a transepiphyseal separation, with [type IA] or without [type IB] dislocation of the femoral head from the acetabulum [3]. Type II is a transcervical fracture. Type III is a cervicotrochanteric fracture. Type IV is an intertrochanteric fracture [3]. Type I transepiphyseal fractures occur through the proximal femoral epiphysis. Such fractures are rare, constituting 8% of femoral neck fractures in children [3, 4]. True transepiphyseal fractures are different from unstable slipped capital femoral epiphysis of the preadolescent, which probably occurs as a result of a subtle endocrinopathy [5]. Approximately half of type I fractures are associated with a dislocation of the capital femoral epiphysis. In such cases, the outcome is dismal because of ON and premature epiphyseal closure in virtually 100% of patients [6, 7]. The current management is directed at early, anatomic reduction of these fractures with stable internal fixation and supplemental external stabilization [casting], with the goal of minimizing devastating late complications [4,8]. Regardless of the mechanism of proximal femoral epiphyseal separation, the prognosis is poor secondary to the development of osteonecrosis [8].
Case Report
A 2 year old female child presented to us with complaints of pain and swelling over left hip region along with inability to bear weight on her left lower limb following a fall from height one week back. Pain was acute in onset, continuous, severe in the beginning but later it was moderate and localized over the anterior aspect of left hip. It was aggravated by limb movement and relieved by rest. There was no radiation of pain. Pain was accompanied by diffuse swelling of the whole left hip region predominantly over the anterior aspect. On examination the swelling was diffuse, soft, localized to upper part of thigh, non-translucent, non-illuminant, non-fluctuant, non-pulsatile and not fixed to the bone. There was deep tenderness over the scarpa’s triangle. Local temperature was slightly raised. Straight leg raising test was negative. Bitrochanteric compression test was positive, and there was supratrochanteric shortening of 1.5 cm on the left side. The limb was in flexion, abduction and external rotation. There was no deformity at the knee. There was painful restriction of all movements of the left hip joint. Routine blood investigations were within normal limits. Plain radiographs of the left hip anteroposterior and lateral views were done. It showed complete separation of proximal femoral epiphysis of the head of the femur [Type I B fracture] and its gross displacement in the medial compartment of proximal thigh region. For further management Magnetic Resonance Imaging [MRI] of the left hip was done. It showed complete traumatic separation of proximal femur epiphysis and its gross displacement in the medial compartment of the thigh. The epiphysis was still viable. The patient was planned for surgery. In supine position the hip joint was opened by anterolateral [Watson Jones] approach. The epiphysis was located with blunt dissection and fluoroscopy. It was replaced back in the acetabulum and transfixed with the help of a k wire. Hip spica was applied. Regular follow up was done every two weeks. It showed migration of the k-wire in the pelvis and premature gradual fusion of the epiphysis with the neck. The k-wire was removed after 10 weeks and full weight bearing was allowed. MRI was again done and it showed a viable epiphysis. After three months there was complete fusion of the epiphysis but there was painless full range of movement of the hip joint. The patient was able to bear weight completely but long term result is awaited.
Discussion
The prevalence of fractures of the hip in children is less than 1%. Therefore, most orthopaedic surgeons will treat only a few such fractures in a lifetime [1, 2]. Most importantly the epiphysis is a significant barrier to interosseous blood supply for the femoral head [1, 3]. Because of this, and the fact that there is little blood supply to the femoral head from the ligamentum teres, an increased risk of necrosis is present following fracture and injury to the retinacular vessels [9, 10]. A transepiphyseal separation can occur in children because of the weak proximal femoral epiphysis [9, 10]. Transcervical and cervicotrochanteric fractures have an extremely high risk for osteonecrosis and coxa vara compared with their adult counterparts [9]. Intertrochanteric fractures are mechanically similar in both groups, although in children involvement of the greater trochanteric apophysis can result in premature closure [8, 10]. The proximal femoral epiphysis is at risk in hip fracture and has obvious implications for fracture care and prognosis [9]. If the proximal epiphysis is damaged, coxa vara, coxa breva, osteonecrosis, premature epiphyseal closure, limb length discrepancy may develop with further growth regardless of fracture alignment [9).
Conclusion
Traumatic separation of the proximal femoral epiphysis is a rare but devastating injury because osteonecrosis occurs in most cases. In our study we found fusion of the proximal femoral epiphysis to the neck after 3 months of postoperative period. There was 5 mm of shortening present in the affected limb after 8 months of postoperative period. Child is doing well; she can stand and walk without any support. Proximal femoral epiphysis is responsible for only 30% of lower limb growth, so good results are predicted. But to comment upon the final outcome a long follow up is awaited.
References
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2. SlongoTF, Hunter JB. Pediatric fractures, femur proximal. In: Rüedi TP, Buckley RE, Moran CG, ed. AO Principles of Fracture Management. New York, NY: Thieme Medical Publishers; 2007:413-417.
3. Swiontkowski MF. Proximal femoral fractures. In: Green NE, Swiontkowski MF, ed. Skeletal Trauma in Children. Philadelphia, PA: Saunders Company; 2003:389-406.
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6. Jarvis J, Davidson D, Letts M. Management of subtrochanteric fractures in skeletally immature adolescents. J Trauma. 2006; 60:613-619.
7. Ratliff AHC. Fractures of the neck of the femur in children. J Bone Joint Surg [Br] 1962;44:528-542.
8. Hughes LO, Beaty JH. Current concepts review: fractures of the head and neck of the femur in children. J Bone Joint Surg [Am] 1994;76:283-292.
9. Barquet A.Natural history of avascular necrosis following traumatic hip dislocation in childhood :a review of 145 cases.Acta Orthop Scand.1982;53:815-20.
10. Canale ST, Beaty JH. Pelvic and hip fractures. In: Rockwood CA Jr, Wilkins KE, Beaty JH, eds. Fractures in children, 4th ed. Philadelphia: Lippincott-Raven, 1996:1109-1193.
| How to Cite This Article: Parekh HP, Dwidmuthe SC, Patil SD, Sonar S. Complex Compound Fracture of Tibia Managed with Distraction Osteogenesis. Journal of Orthopaedic Case Reports 2014 July-Sep;4(3): 56-58. Available from: https://www.jocr.co.in/wp/2014/07/11/2250-0685-198-fulltext/ |
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