Delbet Classification Femoral Neck Fracture in pediatrics

1. Proximal Femoral
Fracture
in Pediatrics
Surachat Jaroenwareekul, M.D.
QSNICH

2. Outline
•Etiology and Prevalence
•Anatomy
•Classification
•Treatment
•Complications
•Points of consideration

3. Introduction
• Rare, less than 1% of all pediatric fracture
• Mainly 10-13 years old
• The bone is very strong in children
• Commonly femoral neck and intertrochanteric fracture, can
occur through physis
• Usually from high energy injury
• If low energy - should suspect pathologic fractures (metabolic,
tumor)

4. Introduction
The hip joint
• Enclosed by a thick fibrous capsule - less likely to tear than in adult hip
fractures
• May lead to a tense hemarthrosis after intracapsular fracture – may
tamponade the ascending cervical vessels
• Surrounded by a protective cuff of musculature - open hip fracture is rare

5. Anatomy
• Ossification center
• Capital femoral epiphysis ossifies at 4 mo girls, and 5-6 mo boys
• Trochanteric apophysis ossifies at 4 years
• Proximal femoral physis
• Metaphyseal growth in the femoral neck
• About 15% length of total femur
• Trochanteric apophysis
• Appositional growth of the greater trochanter
• Shape of proximal femur – damage may cause elongated valgus femoral neck
• Fusion at proximal and trochanteric physis occurs at age 14 in girls and 16 in boys

6. Vascular Supply
• Age 0-4
• Main blood supply is from metaphyseal vessels (interosseous
continuation of branch from med and lat circumflex a.)
• After age 4
• Metaphyseal vss. diminish because physis block, then
intracapsular lateral epiphyseal vessels predominate – terminal
extension of medial circumflex a. - extend superiorly over exterior
of the neck
• Lateral epiphyseal vessels consist
• Posterosuperior branch of medial circumflex a. – predominate
around age 3-4 – can cause anterolat. ON of femoral head if
disrupt - safe via ant. capsulotomy
• Posteroinferior branch of medial circumflex a.
• Ligamentum teres
• Little supply to the femoral head until age 8 – only 20% in adult

7. Mechanism of injury
• Axial loading, torsion, hyperabduction, or a direct blow to the hip
• Almost all hip fractures in children are caused by severe, high-energy
trauma
• Associated head and visceral organ injury in high energy trauma
• Infant without a plausible cause – non-accidental trauma – shoulder
evaluate skin, other extremities, trunk, and head

8. Assessment
• Sign & Symptom
• Shortening, ER, Pain
• Imaging
• Pelvis AP, lateral cross-table
• CT
• MRI
• A linear black line (low signal) on all sequences surround by a high-signal band of bone
marrow edema and hemorrhage
• Ultrasound
• in infant: epiphyseal separation, R/O synovitis/infection

9. Delbet classification
• Typer IA : Transepiphyseal fracture
• Type IB : Transepiphyseal fracture with
dislocation from acetabulum
• Type II : Transcervical fracture
• Type III : Cervicotrochanteric fracture
• Type IV : Intertrochanteric fracture
Incidence – 8% (50/50), 45-50%, 34%, 12%

10. Differential diagnosis
Post-traumatic hip pain without evidence of fracture
• Stress fracture
• Repetitive cyclic loading e.g., football, running
• Vitamin D deficiency, female atheletes
• Compression vs. Tension type
• NWB 6 wks then progressive weight bearing with follow up
• Slipped capital femoral epiphysis
• Legg-Calve-Perthes disease
• Infection (septic arthritis)
• Bony malignancies

11. Delbet type I VS SCFE
DELBET I SCFE
Young children Pre-adolescent
High-energy trauma Low-energy trauma,
Prodromal period
Normal physis Abnormal physis
Obesity,Endocrinopathy

12. Treatment Principle
• Early (< 24 hrs), anatomic, stable reduction - decreased risk AVN
• Treat the fracture first
• Minimizing late complications
• High rate of coxa vara, delayed union, nonunion with conservative
treatment; recommend operative treatment
• Stable internal fixation
• Selective use of supplemental external immobilization (casting)
• Role of decompression – high intracapsular pressure, decrease blood
flow after fracture; restore after decompression and fixation

13. Non-op in non-displaced : type I (< 2 y); type II,III (< 5 y);
type IV (< 3 y)
• Pavlik harness or abduction brace in < 1yr
• Hip spica cast
• position of abduction and neutral rotation
Non-operative Treatment

14. Treatment Type I
Fixation except:
<2 yr + nondisplaced/accepted
CR
IA IB
Age < 2 Age > 2
1 Attempt CR
Non/Minimally
Displaced
Displaced Non/Minimally
Displaced
Displaced
Spica Cast 6
wks
Abd + IR
CR
Gentle traction
Abduction
Internal
Rotation
Stable
Unstable
2.0 mm
K-wires x 2-3
+- arthrogram
CR 2.0 mm
K-wires or
4.0-4.5
mm
cannulated
screws
- should
cross
physis
Failed
Watson-Jones
ORIF
Dislocation Type
Anterior
Inferior
Posterior
Posterior or
Posterolateral
Approach
For older children use 4.0-7.3 mm screws Fx table, anterior capsulotomy

15. Treatment Type II, III
Age
< 5 Yr + stable,
non-displaced
Non/Minimally
Displaced
Anatomic CR
(Traction + Abd + IR)
Spica cast 6 wks
Closed F/U
Displaced or
> 5 Yr
Failed CR -
Watson-Jones
Age < 10
Age 10-12 +
Doubtful in stability
of fixation
≤8 Yr >8 Yr
4.0-4.5 mm
cannulated screws
x 2-3
6.5 mm
cannulated screws
x 2-3
Age > 12 yr with
tranphyseal
fixation
Restrict weight
Fixation except:
<5 yr + nondisplaced
Type II: Cross physis for fixation stability
Type III: no need to cross physis
Avoid penetration of physis
except type II unstable and age
> 12 yrs
Lovell - Cut off at 6 yr

16. Treatment Type IV
Non-displaced
Age < 3 yr
Spica cast 12 wks
Dispalced
Closed Reduction
Traction + IR
Frequent follow up
X-ray
Limited CT
Pediatric compression
hip screw
Fixation except:
<3 yr + nondisplaced
Age > 3 yr
Lovell - Cut off at 6 yr
Neck-shaft > 115 deg
May use side plate

17. Surgical Approach
• Watson-Jones (Anterior Lateral Approach)
• Smith-Peterson (Anterior Approach)
• Surgical Dislocation of the Hip (Ganz)

18. Watson Jones Approach
Most common approach

19. Smith-Peterson Approach

20. Surgical Dislocation of the Hip
May use in IB

21. Surgical Dislocation of the Hip

22. Post-op Care
• Type I: spica cast all patients, except adolescents fixed with large
screws, compliance for NWB
• Type II, III: spica cast all patients that fixation not cross physis, except
adolescents that was fixed cross physis
• Type IV: not require cast (because DHS fixation is strong, stable)

23. Complications
•Avascular necrosis*
• Most common
• I:II:III:IV = 38:28:18:5
• IB = 100%
•Malunion (coxa vara)
• 20%
• Age < 8 yr, NSA > 110: good remodeling
• Subtrochanteric valgus osteotomy
•Traumatic physeal arrest
• Common in type II, III
• Tx LLD (>2.5 cm) - may use greater
trochanteric epiphysiodesis
•Nonunion**
• 6-10%
• Diagnosis > 6 months
• Rx: stable internal fixation
• Subtrochanteric valgus osteotomy

24. Quality of Reduction

25. Complications
• Significant risk of AVN in Delbet I/II
• The quality of reduction postoperatively was evaluated according
to fracture alignment as the modified radiographic criteria and
scored as good and not good. Good alignment was defined as
< 4-mm step-off and < 5-degree angulation

26. Osteonecrosis
• The most common and serious complication
• Sign & Symptoms usually develop within 1 year
• Risk factor : Type IB, II, III, Displacement,
Poor quality of reduction and fixation
Older age at time of injury
Delay treatment
Increase intracapsular pressure
• Incidence %
IB I II III IV Overall
100 38 28 18 5 30
Ratliff classification

27. Osteonecrosis
Investigation: MRI at 2 weeks, isotope bone scan 4 months
Treatment: Controversy, Inconclusive
• Prolonged NWB
• Bisphosphonate – improved outcome at 3 year
• Redirection osteotomy
• Distraction arthroplasty + external fixation
• Core decompression
• Vascularized fibular graft

29. Point of Consideration
•Urgency of Treatment
•Points of Concern
•Choice of fixation

30. Urgency of Treatment
•Consideration of compromised vascular supply
•IB > IA > II > III > IV
•IA – Gap of Separation -> Risk AVN
•II – likely disrupt vascular supply of reticular branch -> Risk AVN
•III – Basicervical neck -> Less AVN

31. Points of Concern
•Type IB – Need Open Reduction
•Type IA, II - Urgent Reduction
• Should reduction with fixation since stability cannot be accessed
•Type III – Stress riser from load; cause delayed/malunion

32. Choice of Fixation
• Stability of fixation
• Cannulated screw cross physis - Physeal arrest
• May combined implant if cross-physeal fixation is need
• Smooth pin cross physis augmented with cannulated screw near
physis
• Basicervical fracture
• May consider side plate fixation to prevent coxa vara – stress over
basicervical femoral neck
• Dynamic hip screw – controlled collapsed and compression,
stress transfer, more biomechanical advantage than screws - may
not suitable in femoral neck of younger patient
• May use hip osteotomy plate – less damage to intramedullary
bone over neck

33. Thank you