Reduction of Neglected Displaced Fractures of the Distal Femoral Physis.

BACKGROUND: We performed open osteoclasis, soft-tissue release, and fracture fragment reduction and fixation to treat 10 cases of neglected physeal fractures of the distal aspect of the femur with severe deformity. To our knowledge, no specific surgical procedure for this problem has been reported in the literature. DESCRIPTION: The procedure is typically performed through an extensile anterolateral approach. With use of an osteotome, the typically abundant fracture callus is disrupted and partially removed to recreate the original fracture line. Through periosteal dissection, an extensive musculoperiosteal detachment and release is achieved to facilitate fracture reduction while protecting the physis from further injury. ALTERNATIVES: Knee rehabilitation in closed, nondisplaced or minimally displaced fractures1.Open callus osteoclasis in combination with a Z-shaped quadriceps tenoplasty, reduction, and plaster cast immobilization2.Open subperiosteal osteoclasis, reduction, and tibial traction3.Open callus osteoclasis, reduction, and condylar plating4.Sequestrectomy with preservation of a periosteal sleeve to treat osteomyelitis complicating an open fracture1.Transfemoral amputation to treat gas gangrene or vascular injury following severe open injury1,5-7. RATIONALE: This procedure was developed in remote medical facilities where patients are often first seen >21 days after the original injury. By that time, closed reduction or standard open reduction and internal fixation techniques are no longer possible. After 6 months of fracture age, the procedure is inefficient. EXPECTED OUTCOMES: This procedure allows correction of limb malalignment and shortening while preserving the growth plate1. IMPORTANT TIPS: In some cases, hypertrophic fracture callus might be mistaken for the femoral diaphysis.An extensive musculoperiosteal release will facilitate reduction of the fracture fragments.The adequacy of reduction must be assessed in all 3 planes intraoperatively.The adequacy of reduction must be assessed in all 3 planes intraoperatively.The adequacy of reduction must be assessed in all 3 planes intraoperatively.