This document discusses pediatric femoral neck fractures. Key points: - They are rare, accounting for less than 1% of pediatric fractures. Anatomy and blood supply make complications like avascular necrosis more common. - Delbet classification includes 4 types based on fracture location. Type 1 is through the physis, Type 2 through the neck, Type 3 at the base of neck, and Type 4 is intertrochanteric. - Treatment depends on type and stability but generally involves closed or open reduction and fixation or spica casting. Complications include avascular necrosis, coxa vara, premature physeal closure, and nonunion. Close follow up is needed due to risk of late complications.

1. PAEDIATRIC FRACTURE NECK OF
FEMUR

2. < 1% of all pediatric #
<1 % of prevalence of hip # in adults.
Exceedingly rare.

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. 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. 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. 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. 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. VASCULAR ANATOMY

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. 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. 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. 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. TYPE 1

14. TYPE 1 TRANSEPIPHYSEAL – through
the physis

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. TYPE 2

17. TYPE 2 TRANSCERVICAL- through
neck

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. TYPE 3

20. TYPE 3 CERVICOTROCHANTERIC –
base of neck

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. TYPE 4 INTERTROCHANTERIC

23. 12 % of NOF #.
Lowest complication rate
Good healing.
Nonunion & AVN rare.

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. 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. Radioisotopic bone scan  48 hrs after onset, increased
uptake in # site.
MRI  detects # with in first 24 hrs.

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. < 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. TYPE 1 B
One attempt CR, if not immediate OR from the side of
dislocation.
Generally posterolateral approach.

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,

32. TYPE IV
Good results with traction & spica, regardless of
displacement.
Indications for IR
- failure to maintain reduction
- polytrauma
- older children
Pediatric hip screw.

33. 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,

34. 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.

35. 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.

37. 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.

38. Late stage

39. 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]

40. 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.

41. 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.

42. others
Infections [1%]
Chondrolysis [ hardware placed inside Jt].

43. 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 classification
1. Compression - non wt bearing, coxa vara.
2. Tension – inherently unstable, insitu fixation