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Neck of Femur

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Neck of Femur

  1. 1. PAEDIATRIC FRACTURE NECK OF FEMUR
  2. 2. < 1% of all pediatric #<1 % of prevalence of hip # in adults.Exceedingly rare.
  3. 3. Difference from adultAnatomyProximal femoral epiphysis is at a risk of fractureOrientation of trabeculae in femoral neck in children is not along the stress linesSmooth Fracture surfaces, with very little interlocking impaction  closed reduction less stable.
  4. 4. Blood vessels to the femoral head are easily damaged, and a high incidence of AVN occurs in fractures in children than adults.Growth arrest in the physis can cause shortening of up to 15% of the total extremity Varus or valgus angulation of the femoral neck also can occur from arrest of only one side of the physis.
  5. 5. A child can tolerate immobilization much more readily than an adult, and thus more choices for treatment are available, including traction, a spica cast, and bed rest, in addition to operative treatment.Fixation devices causes growth arrest.
  6. 6. MECHANISM OF INJURYAxial loading, torsion, hyperabduction or a direct blow injury.Severe high energy trauma.Proximal femur in children is extremely strongFracture after minor injury suggests weaker bone.Bone cysts, infection.
  7. 7. Applied AnatomyDuring early childhood only a single proximal femoral physis exists.During I yr of life medial portion grows faster creating long neck.PFE begins to ossify at 4 – 6 months.Trochanteric apophysis – 4 yrs.PFP  metaphyseal growth of the neckFusion of physis  14 – 16 yrs.
  8. 8. VASCULAR ANATOMY
  9. 9. Ligamentum teres little B.SAt birth Metaphyseal vessels predominate.Gradually diminish as physis develops. [barrier], non existent by 4 yrs.Lateral epiphyseal vessels – posterosuperior & posteroinferior branches of MCFAAt intertrochanteric groove, MCFA branches in to the retinacular arterial system.
  10. 10. Capsulotomy does not damage B.S but violation of IT notch or LACV  avascular.At 3-4 yrs, lateral posterosuperior vessels appear to predominate.PI & PS vessels persists through out life.Multiple small vessels coalesce with age.
  11. 11. Confluence of GT physis with capital femoral epiphysis along the superior femoral neck & unique vascular supply to CFE makes immature hip vulnerable to growth derangement & subsequent deformity after a fracture.
  12. 12. DELBET CLASSIFICATIONTYPE I : Transepiphyseal separation I A : With dislocation II B: With out dislocation.TYPE II : Transcervical fractureTYPE III : Cervicotrochanteric fracture.TYPE IV : Intertrochanteric fracture.
  13. 13. TYPE 1
  14. 14. TYPE 1 TRANSEPIPHYSEAL – throughthe physis
  15. 15. High energy trauma8 % of NOFIn a new born during a difficult breach delivery [proximal femoral epiphysiolysis] mistaken with DDH.During CR of traumatic dislocations hip.50% @ with dislocation of CFE.(100% complication) < 2 yrs of age better prognosis. AVN unlikely but other comp, can occur.
  16. 16. TYPE 2
  17. 17. TYPE 2 TRANSCERVICAL- throughneck
  18. 18. 46% of # NOFMost common typeDifficult to treat in spica.70% displaced at presentationIncidence of AVN related to initial displacement.AVN  50% [ common comp].
  19. 19. TYPE 3
  20. 20. TYPE 3 CERVICOTROCHANTERIC –base of neck
  21. 21. Located at or above anterior IT line.2 nd most common.34% of NOF #AVN 20-30%Premature physeal closure  25%.Coxa vara  14%.
  22. 22. TYPE 4 INTERTROCHANTERIC
  23. 23. 12 % of NOF #.Lowest complication rateGood healing.Nonunion & AVN rare.
  24. 24. Type 1 # in neonateExceedingly rareA strong suspicion, [F.H not visible] pseudoparalysis & shortening – key for diagnosis.holds the limb in flexed, abducted & ext. rotated.DD – septic arthritis & hip dislocation.High riding PF metaphysis.USG.
  25. 25. Clinical featuresPain in the hipShortened & externally rotated limb.Non displaced #  walk with limp.INVESTIGATIONS:X ray pelvis AP & Cross table lateral view.Any Break or offset of bony trabeculae near Ward’s triangle  impacted #.
  26. 26. Radioisotopic bone scan  48 hrs after onset, increased uptake in # site.MRI  detects # with in first 24 hrs.
  27. 27. TREATMENT type -IBased on age & fracture stability after reduction.< 2 yrs with minimally displaced #, CR & spica cast application.# tends to displace in to varus & ext.rotation, limb should be in mild abduction & neutral rot.Displaced # reduced by gentle traction, abduction & IR.
  28. 28. < 6-8 Yrs smooth pins> 8 Yrs  cannulated cancellous screwsOlder children should undergo fixation even undisplaced.Postop spica must in all except for adolescents.Implants removed shortly # healing [8-12 wks]
  29. 29. TYPE 1 BOne attempt CR, if not immediate OR from the side of dislocation.Generally posterolateral approach.
  30. 30. TYPE II & IIIAnatomic reduction & stable IF always indicated to minimize risk of complications.Non displaced type 2 # in children < 5 yrs  spica, wants close follow-up.Open reduction  Watson & Jones approachScrews to be inserted short of physis.If not good purchase penetrate the physis.Treatment of # is priority, growth disturbance & LLD are secondary,
  31. 31. TYPE IVGood results with traction & spica, regardless of displacement.Indications for IR - failure to maintain reduction - polytrauma - older childrenPediatric hip screw.
  32. 32. SURGICAL TIPSAlways predrill & tap before inserting screws.Avoid crossing the physis but cross it if necessary for stability.Postop, hip spica for 6-12 wks if < 10 yrs,
  33. 33. COMPLICATIONS:-Avascular necrosisMost serious & most frequentOverall prevalence 30%.Primary cause of poor results.Highest after type IB, II, III.Initial # displacement, damage to blood vessels, # hematoma.
  34. 34. RATLIFF CLASSIFICATIONTYPE I : Involvement of whole head - most severe & most common form - poorest prognosis -damage to all lateral epiphyseal vesselsTYPE II: Partial involvement - localized damage to one or more LEV.TYPE III: an area of AVN from # to physis - damage to superior metaphyseal V. - rare but good prognosis.
  35. 35. X ray ; as early as 6 wks, decreased density of FH with widening of jt space.Can develop as late as 2 yrs, so all pt to be followed for atleast 2 yrs.Tc bone scanMRI; no AVN with in 6 wks ,it is unlikely to occur.
  36. 36. Late stage
  37. 37. COXA VARA20-30% prevalenceLower in internal fixed pts.causes: malunion, AVN, premature physeal closure or a combination of above.Raises GT in relation to FH causing shortening of extremity & abductor lurch.Subtrochanteric valgus osteotomy if C.vara persists > 2 yrs. [>110*, in > 8 yrs]
  38. 38. PREMATURE PHYSEAL CLOSURE28% of #Risk increases with penetration of fixation devices or when AVNM.F after type II or III AVN.Shortening not significant except in youngerTrochanteric epiphysiodesis – progressive coxa vara.
  39. 39. NON UNION7% of #Not seen after type 1 & IVPrimary cause – failure to obtain or maintain reduction.If the child had pain & no bridging new bone at 3 months post injury.Subtrochanteric valgus osteotomy / rigid IR +/- bone grafting.
  40. 40. othersInfections [1%]Chondrolysis [ hardware placed inside Jt].
  41. 41. STRESS FRACTURE Repetitive cycle loading of hip by new or increased activity. Adolescent female athlete, anorexia nervosa, & osteoporosis. X rays only reveal after 4-6 wks DEVAS classification1. Compression - non wt bearing, coxa vara.2. Tension – inherently unstable, insitu fixation

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