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Images summary Proximal Femur Fractures in the pediatric poplulation are rare fractures caused by high-energy trauma and are often associated with polytrauma. Diagnosis can be made with plain radiographs of the hip. Treatment is usually operative with the technique depending on the age of the patient and the Delbet classification type of fracture.
Epidemiology
Incidence
accounts for < 1% of pediatric fractures
Demographics
males more commonly affected 2.5:1
bimodal distribution
children < 2-3 years old due to non-accidental trauma
adolescents involved in motor vehicle accidents
Etiology
Pathophysiology
mechanism of injury
usually results from high-energy trauma (75-80%)
can result from low-energy trauma if the patient has weakened bone (i.e. tumors, metabolic bone disease)
Associated conditions
30-85% of patients will have associated traumatic injuries
head or facial trauma
splenic lacerations
retroperitoneal hemorrhage
perineal injury
pelvic ring or acetabular fractures
hip dislocation
femur fractures
associated complications
AVN
premature physeal closure
Anatomy
Osteology
proximal femur develops from 2 centers of ossification
proximal femoral epiphysis
ossification begins at 4-6 months in girls and 5-7 months in boys
responsible for metaphyseal growth of femoral neck
rate of growth is 3 mm/year
accounts for 13-15% of overall leg length
accounts for 30% of overall femur length
trochanteric apophysis
ossification begins at 4 years in both girls and boys
responsible for appositional growth of greater trochanter
also makes small contribution to growth of femoral neck and intertrochanteric femur
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
Blood supply
medial femoral circumflex artery (MFCA)
via the posterosuperior and posteroinferior retinacular branches
at birth, contributes to the blood supply to the head with the LFCA and artery of ligamentum teres
at 4 years old, becomes the main blood supply after regression of the LFCA and artery of ligamentum teres
lateral femoral circumflex artery (LFCA)
at birth, contributes to the blood supply to the head
regresses in late childhood
artery of the ligamentum teres
at birth, contributes to the blood supply to the head
diminishes after 4 years old
metaphyseal vessels
also contribute to blood supply to the head < 3 years old and after 14-17 years
between 3 to 14-17 years, the physis blocks metaphyseal supply
after 14-17 years, anastomoses between metaphyseal-epiphyseal vessels develop
Neurovascular
superior gluteal nerve (L4, L5, S1)
gluteus medius
gluteus minimus
Presentation
Symptoms
severe pain in affected hip
inability to bear weight
Physical exam
shortened, externally rotated lower extremity
Classification
Delbet Classification
Description
Incidence
AVN
Nonunion
Type I
Transphyseal (with or without epiphyseal dislocation)
<10%
38%-100%
Type II
Transcervical
40-50%
28%
15%
Type III
Cervicotrochanteric (or basicervical)
30-35%
18%
15-20%
Type IV
Intertrochanteric
10-20%
5%
5%
Imaging
Radiographs
recommended views
AP
cross-table lateral
optional views
bone survey if suspected non-accidental trauma
findings
break/offset of bony trabeculae near Ward triangle
indicates nondisplaced or impacted fracture
CT
indications
nondisplaced fractures and stress fractures
MRI
indications
nondisplaced fractures and stress fractures (preferred over CT)
pathologic fractures
findings
well-defined low-signal line and surrounding high-signal bone edema on T2-weighted images
Ultrasound
indications
nondisplaced fractures in infants
findings
hemarthrosis
difficult to differentiate from effusion due to inflammation or infection
subtle epiphyseal mobility
Differential
Legg-Calve-Perthes disease
Toxic synovitis
Spontaneous hemarthrosis
Infection
Treatment
Nonoperative
closed reduction and spica abduction casting
indications (rarely indicated)
Type I without epiphyseal dislocation, II, III, IV IF nondisplaced/minimally displaced AND < 4 years old
evaluate type I fractures for non-accidental trauma if young (< 2-3 years old)
Operative
emergent ORIF with capsulotomy (or joint aspiration)
indications
open hip fractures (rare)
vessel injury where large vessel repair is required (rare)
concomitant hip or epiphyseal dislocations (especially type I)
fractures with significant displacement
some data suggests this may decrease the rate of AVN
closed reduction percutaneous pinning (CRPP)
indications
type I (without epiphyseal dislocation), II, III if displaced and/or > 4 years old
fixation
smooth pins may be adequate in young patients if postoperative spica casting performed
cannulated screws in older patients and adolescents
postop
fracture brace or spica cast if there is concern that the long lever arm of the leg could contribute to loss of fixation of the fracture
ORIF with pin/screw fixation
indications
type I II, III if unable to achieve closed anatomic reduction
postop
consider fracture brace or spica cast if concern for stability of fracture
ORIF with sliding hip screw (DHS)
indications
type IV if displaced or > 4 years old
Techniques
Closed reduction and spica abduction casting
timing of reduction
early reduction (< 24h) may diminish risk of AVN by restoring blood flow through kinked vessels
technique
fracture table (preferred for most patients)
can use radiolucent table for younger patients
apply gentle longitudinal traction with abduction and internal rotation
follow with weekly radiographs for 3 weeks to make sure reduction maintained
acceptable alignment
type II
accept < 2mm cortical translation, < 5° of angulation, no malrotation
type III and IV
accept < 10° of angulation
Emergent ORIF with capsulotomy (or joint aspiration)
may decrease AVN
technique
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
instrumentation
smooth or threaded pins/K wires
indications
type I without epiphyseal dislocation, II, III in patients < 4yrs
cannulated screws
indications
type I without epiphyseal dislocation, II, III in patients > 4yrs
technique
pin/screw placement
short of the physis
indications
patients < 4-6yrs
most type III fractures
less stable than transphyseal
transphyseal
indications
older patients close to skeletal maturity (> 12yrs old)
when there is little metaphyseal bone available
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
postop immobilization
post-op spica casting (abduction and internal rotation) for 6-12 weeks if < 4yrs or pin/screw placement short of the physis
long lever arm of the leg could contribute to loss of fixation of the fracture
ORIF with pin/screw fixation
approach
anterolateral (Watson-Jones)
instrumentation/technique
see above
ORIF with DHS
approach
lateral (Hardinge)
instrumentation
pediatric hip screw
-
Complications
AVN
most common complication
risk factors
age
risk increases 1.14 times for every year of increasing age
fracture type
highest risk with type I (transphyseal) fractures
nearly 100% if epiphyseal dislocation
delayed reduction > 24 hours
-
inadequate/unstable reduction
etiology
kinking/laceration of vessels
tamponade by intracapsular hematoma
classification - Ratliff
type I - involvement of whole head
type II - partial involvement of head
type III - area of necrosis in femoral neck from fracture line to physis
treatment
core decompression
vascularized fibular graft
Coxa vara (neck-shaft angle <120°)
2nd most common complication
risk factors
more common if fracture is treated non-operatively
more common for type I, II and III fractures
incidence 25% for type III
treatment
young patients (0-3 yrs) will remodel if neck-shaft angle > 110°
surgical arrest of trochanteric apophysis
indications
mild coxa vara in < 6-8 yrs
only works in younger patients
subtrochanteric or intertrochanteric valgus osteotomy
indications
coxa vara with nonunion
coxa vara with severe Trendelenburg limp or signs/symptoms of FAI
older patients
Coxa valga
seen in type IV fractures involving GT in younger patients
due to premature GT apophysis closure
Nonunion
can occur together with coxa vara (see above)
etiology
nonoperative treatment of type II or III fractures
occult infection at fracture site
malreduced fracture
treatment
ORIF and immobilization (spica cast if younger patient)
subtrochanteric or intertrochanteric valgus osteotomy
bone grafting if persistent
Physeal arrest
can lead to leg length discrepancy
proximal femoral physis contributes to 15% of overall limb length (3 mm/yr)
significant (> 2cm) leg length discrepancy is rare and only occurs in very young children
risk factors
penetration of physis by fixation devices
AVN
more common in patients with type II or III AVN
Limb length discrepancy (LLD)
significant LLD occurs in combined AVN and physeal arrest
treatment
shoe lift if projected LLD at skeletal maturity is < 2cm
epiphysiodesis of contralateral distal femur ± proximal tibia if projected LLD at skeletal maturity is 2-5cm
Chondrolysis
usually associated with AVN
etiology
poor vascularity to femoral head cartilage
penetration of hardware into joint
presents as restricted hip motion, hip pain, radiographic joint space narrowing
Malreduction
common with subtrochanteric fractures
deforming forces lead to proximal fragment in flexion, abduction, and external rotation
Infection
Prognosis
Poor functional outcomes have been associated with
head trauma
amputation
peripheral neurological damage
AVN
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(SBQ13PE.52) Which of the following
injuries is associated with highest incidence of osteonecrosis? QID: 5115 69-year-old male with a valgus impacted three-part proximal humerus fracture 89-year-old female with a valgus impacted (Garden I) femoral neck fracture 14-year-old male with a displaced distal femoral physeal fracture 13-year-old female with a displaced
transcervical femoral neck fracture 42-year-old male with a closed 5th metatarsal fracture at the metaphyseal-diaphyseal junction L 2 B Select Answer to see Preferred Response
(OBQ13.151) A 14-year-old male sustains the injuries shown in Figures A and B after a fall off the roof of his house. What is the most appropriate management?
QID: 4786
Dynamic hip screw with trochanteric side plate
Physis-sparing cancellous screws
Transphyseal cancellous screws
L 3 C
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(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?
QID: 4584
Time to definitive surgical procedure has no effect on outcome
Open reduction with capsular decompression is contraindicated
Internal fixation with a cephalomedullary nail leads to higher union rates than screw fixation
Nonunion is the most common complication if surgical intervention is performed
Closed reduction and cannulated screw fixation across the physis is an acceptable form of surgical management
L 3 C
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(OBQ06.113) What is the most common complication following surgical fixation for the fracture shown in Figure A in an 8-year-old boy?
QID: 299
Clinically significant limb length discrepancy
L 2 C
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