Executive Editor: Fergal Monsell General Editor: Chris Colton

Authors: Andrew Howard, James Hunter, Theddy Slongo

Pediatric proximal femur 31-M/7

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Glossary

1 Preliminary remarks top

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Introduction

An avulsion of the greater trochanter, with disruption of the abductor mechanism can be repaired by open reduction and screw or tension band fixation depending on the size of the avulsed fragment.

It is essential to ensure that the bony fragment is sufficiently large or it may split when screws are inserted. A tension band wire technique is a good alternative for smaller fragments.

For children with 4 or more years of growth remaining, removing the screws should be considered.


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Approach selection

The fracture fragment is approached with a lateral approach, the hematoma is evacuated and periosteum is cleared to allow accurate reduction of the fragment(s).


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Equipment selection

The following implants are required:

  • 3.5, or 4.5 mm cortex screws

The choice of implant depends on the age and size of the child.

Washers are optional depending on the bone quality and fracture configuration.

2 Reduction top

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The trochanteric fragment is directly reduced to its bed and the position confirmed using image intensification. A towel clip may be used for temporary control, or a K-wire can be used to aid manipulation and to provide temporary fixation.

3 Fixation top

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Guide wire insertion

The first K-wire is placed in the center of the proximal part of the greater trochanter.

There are several surgical options that depend on the available implants and the surgeon’s experience.


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Cortex screw fixation

The initial K-wire holds the trochanteric fragment in place.

A 2.5 or 3.2 mm drill is used to make a drill hole in the distal part of the greater trochanter, perforating the cortex on the calcar side.

The screw length is measured.


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A 3.5 or 4.5 mm self-tapping cortex screw is inserted and tightened.


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The K-wire is removed and a second drill hole is made at the site of insertion.

The screw length is measured.


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A 3.5 or 4.5 mm self-tapping cortex screw is inserted and tightened.


Closure

Routine closure according to the surgeon's preference.

4 Postoperative protocol top

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It is important to avoid active contraction and passive movement of the corresponding muscle. Therefore, good instructions from the surgeon and/or physiotherapist are helpful.

Crutch walking with toe-touch weight bearing, supervised by a physiotherapist, should be advised for 3-4 weeks.


Follow up

Abductor strengthening exercises can be started after 6-8 weeks if there are clinical and radiological signs of healing.

v1.0 2017-12-04