Traumatic Injuries of the Knee by E. Carlos Rodríguez-Merchán

Author:E. Carlos Rodríguez-Merchán
Language: eng
Format: epub
Publisher: Springer Milan, Milano

6.6.4 Treatment of Pediatric Floating Knee

The literature on pediatric floating knee is much more limited, since such injuries are even less common in the pediatric population. The first authors to publish a series exclusively involving patients under 15 years of age were Letts et al., in 1986, who introduced a new classification with implications for treatment [5]. In type A fractures (diaphyseal fractures of both bones), these authors recommend open reduction and fixation of the tibial fracture and skeletal traction of the femur. In type B injuries (one metaphyseal fracture), they use open reduction and fixation of the diaphyseal fracture and traction or plaster applied to the metaphyseal fracture. On the other hand, in type C fractures (one epiphysiolysis and one diaphyseal fracture), they recommend open reduction and internal fixation of the epiphysiolysis, with traction or plaster applied to the other fracture. In turn, type D fractures (one open fracture) are subjected to débridement and external fixation of the open fracture, with traction in the case of the closed fracture. Lastly, in type E fractures (open fractures of both bones), the authors perform external fixation of the tibial fracture and traction or external fixation of the femoral fracture. According to Letts et al., at least one of the two fractures should be rigidly fixed, the tibial fracture being the most appropriate candidate in most cases.

The authors also emphasized the age of the patients. In older children, intramedullary nailing of the femur and tibia may be more suitable than plate fixation. In children under 6 years of age, stable closed reduction of the tibia can be achieved and maintained with a cast, while the femur is kept under traction. Surgical treatment of both fractures was not recommended, since this could give rise to overgrowth of the fractured extremity.

In 1991, Bohn and Durbin reviewed a series of 44 children and recommended conservative management of both fractures in patients under 10 years of age [6]. The indications of surgery for femoral fracture are serious head injuries, adolescents, significant soft tissue damage, and the impossibility of achieving adequate reduction through closed methods.

Yue et al. were not in agreement with these recommendations [18], however, since in their series of 30 patients followed-up for an average of 8.6 years, fewer complications (leg length discrepancies, delayed union, or deformities) and a shorter hospital stay were recorded in the patients subjected to surgery of both fractures, despite the fact that these individuals presented a poorer condition upon admission, as reflected by a poorer ISS score. These authors advised rigid stabilization at least of the femoral fracture, and preferably of both fractures, in patients belonging to any age group.

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