Proximal Femur Fractures - Pediatric

Topic updated on 07/24/16 5:14pm
  • Overview
    • challenging because of the high rates of complications 
      • AVN
      • coxa vara malunion
  • Pathophysiology
    • mechanism
      • high energy trauma (75-80%)
      • Type I can occur in newborns after breech delivery
        • similar to Salter Harris I injury
  • Prognosis
    • timing of treatment impact prognosis
      • Delbet type I to III are surgical emergencies
  • Growth centers of the proximal femur
    • proximal femoral epiphysis
      • accounts for 13-15% of leg length
      • accounts for 30% length of femur
      • proximal femoral physis grows 3 mm/yr
      • entire lower limb grows 23 mm/yr
    • trochanteric apophysis
      • traction apophysis
      • contributes to femoral neck growth
      • disordered growth
        • injury to the GT apophysis leads to shortening of the GT and coxa valga
        • overgrowth of the GT apophysis leads to coxa vara 
  • Vascularity 
    • medial femoral circumflex artery
      • main blood supply to the head via the posterosuperior lateral epiphyseal branch and via posteroinferior retinacular branch  
      • becomes main blood supply after 4 years after regression of LFCA and artery of ligamentum teres
    • lateral femoral circumflex artery
      • regresses in late childhood 
    • artery of the ligamentum teres
      • diminishes after 4 years old
    • metaphyseal vessels
      • also contribute to blood supply to the head < 3 years old and after 14-17years
        • between 3 to 14-17 years, the physis blocks metaphyseal supply
        • after 14-17 years, anastomoses between metaphyseal-epiphyseal vessels develop
  • Neurovacular
    • superior gluteal nerve (L5, S1, S2)  
      • gluteus medius   and gluteus minimus  
Delbet Classification  
 Type Description Incidence AVN Nonunion  Images
Type I Transphyseal (IA, without dislocation of epiphysis from acetabulum; IB, with dislocation of epiphysis) <10%
Type II Transcervical 40-50%
Type III Cervicotrochanteric (or basicervical) 30-35% 18%
Type IV Intertrochanteric 10-20 5% 5%   
  • Radiographs
    • AP pelvis and cross-table lateral
  • CT
    • for nondisplaced fractures and stress fractures
  • MRI
    • for nondisplaced fractures and stress fractures
  • Nonoperative
    • spica cast in abduction, weekly radiographs for 3wks
      • indications
        • Type IA, II, III, IV, nondisplaced, <4yrs
          • evaluate Type IA fractures for child abuse
  • Operative 
    • emergent ORIF, capsulotomy, or joint aspiration
      • indications
        • open hip fracture
        • vessel injury where large vessel repair is required
        • concomitant hip dislocation or significant displacement, especially type I
          • may decrease the rate of AVN (supporting data equivocal)
    • closed reduction internal fixation (CRIF)/ percutaneous pinning (CRPP)
      • indications
        • Type II, displaced
          • postop spica (abduction and internal rotation) x 6-12wk
        • Type III and IV, displaced and older children
    • open reduction and internal fixation (ORIF)
      • indications
        • Type IB
    • pediatric hip screw / DHS
      • indications
        • Type IV
  • Emergent reduction and capsulotomy 
    • timing of reduction
      • early reduction (<24h) may diminish risk of AVN
        • by restoring blood flow through kinked vessels
    • reduction technique
      • age 0-10 years
        • on radiolucent table
      • age >10 years
        • on fracture table
    • acceptable alignment
      • Type II
        • accept <2mm cortical translation, <5 degrees of angulation, no malrotation
      • Type III and IV
        • accept <10 degrees of angulation
    • capsulotomy
      • may decrease AVN
      • aspiration with large bore needle through subadductor/anterior hip approach
      • open capsulotomy through anterior incision
  • Closed reduction and percutaneous pinning (CRPP)
    • reduction technique
      • see above
    • fixation
      • smooth or threaded pins / K wires (use 2-3 pins or wires)
        • indications
          • younger patients
          • transphyseal
            • recommended when there is little metaphyseal bone available
      • cannulated screws    
        • indications 
          • short of the physis
            • less stable than transphyseal
            • for patients <4-6yrs
          • transphyseal 
            • older patients close to skeletal maturity (>12yrs old)
            • where crossing the physis is necessary to achieve stable fixation
              • it is easier to treat leg length discrepancy from premature physeal closure than nonunion
            • place within 5mm of subchondral bone
            • avoid anterolateral quadrant of epiphysis and posterior perforation of femoral neck
              • to prevent injury to vasculature
  • Closed reduction and internal fixation (CRIF)
    • indications
      • type IV
      • appropriate if immediately available
    • implants
      • pediatric hip screws   
  • Open reduction and internal fixation (ORIF)
    • approach
      • anterolateral (Watson-Jones) for  types I, II, III
      • lateral (Hardinge) for type IV
  • AVN  
    • most common complication
      • most susceptible age for AVN is 3-8 years
      • risk of AVN is highest for Delbet type I and nearly 100% for Delbet type IB   
    • etiology
      • kinking of vessels
      • laceration of vessels
      • tamponade by intracapsular hematoma
    • treatment
      • core decompression
      • vascularized fibular graft
  • Coxa vara (neck-shaft angle <130deg)
    • 2nd most common complication
    • more common if fracture is treated non-operatively
    • more common for types I, II and III 
      • incidence 25% for type III
    • treatment
      • young patients (0-3yrs) will remodel
      • surgical arrest of trochanteric apophysis
        • indication
          • coxa vara in <6-8yrs
      • subtrochanteric or intertrochanteric valgus osteotomy
        • indication
          • coxa vara + nonunion  
          • coxa vara with severe Trendelenburg limp or FAI signs and symptoms
  • Nonunion    
    • can occur together with coxa vara (see above)
    • etiology
      • nonoperative treatment of Type II or III
      • occult infection at fracture site
      • severe AVN of proximal femur
    • treatment
      • subtrochanteric or intertrochanteric valgus osteotomy
  • Coxa valga
    • Type IV fractures with involvement of the greater trochanter may have premature closure of the GT apophysis, leading to coxa valga
  • Physeal arrest
    • physeal arrest alone leads to <1.5cm leg length discrepancy
      • only in very young children
      • proximal femoral physis contributes to 15% of limb length (3mm/yr)
  • Limb length discrepancy
    • significant LLD occurs in combined AVN + physeal arrest
    • treatment
      • shoe lift
        • indications
          • projected LLD at skeletal maturity <2cm
      • epiphysiodesis of contralateral distal femur and/or proximal tibia
        • indications
          • projected LLD at skeletal maturity 2-5cm
  • Chondrolysis
    • usually associated with AVN
    • etiology
      • poor vascularity to femoral head cartilage
      • persistent hardware penetration of joint
    • presents as restricted hip motion, hip pain, radiographic joint space narrowing
  • Malreduction
    • common with subtrochanteric fractures
      • deforming forces on proximal fragment
        • displaced into flexion, abduction, and external rotation  
  • Infection
    • <1% incidence
    • after ORIF or CRPP
    • treatment
      • debridement, maintain fixation until union
    • may lead to osteomyelitis, AVN, chondrolysis, premature physeal closure


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Qbank (8 Questions)

(OBQ12.224) A 13-year-old female falls and sustains the injury shown in Figure A. Which of the following statements is true regarding the treatment of this condition? Topic Review Topic
FIGURES: A          

1. Time to definitive surgical procedure has no effect on outcome
2. Open reduction with capsular decompression is contraindicated
3. Internal fixation with a cephalomedullary nail leads to higher union rates than screw fixation
4. Nonunion is the most common complication if surgical intervention is performed
5. Closed reduction and cannulated screw fixation across the physis is an acceptable form of surgical management

(OBQ06.113) What is the most common complication following surgical fixation for the fracture shown in Figure A in an 8-year-old boy? Topic Review Topic
FIGURES: A          

1. Coxa valga
2. Chondrolysis
3. Stiffness
4. Clinically significant limb length discrepancy
5. Avascular necrosis

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