Fractures of the femoral neck in children can have high complication rates. Type II fractures have the highest risk of avascular necrosis (AVN) at 50%. Internal fixation is now preferred over casting for displaced fractures to reduce complications like coxa vara and nonunion. AVN is the most common complication and is associated with fracture displacement and hematoma formation. Urgent surgical decompression may reduce AVN risks. Hip dislocations also have risks of AVN and are treated with prompt closed reduction or open reduction if closed fails.

1. Fractures and Dislocations
about the Hip
in the Pediatric Patient
Mark Tenholder, MD

2. • “Hip fractures in children are of interest
because of the frequency of complications
rather than the frequency of fractures.”
• Canale

3. • 1. Rare fracture
• 2. High complication rate
• 3. Emergency?

4. Displaced Femoral Neck Fracture

5. Not Adults
• High-energy
• Thick periosteum
• Vascularity
• Physes
• Treatment options

6. Osseous Anatomy
• Proximal femoral physis
• Trochanteric apophysis
• Dense bone
• Small neck

7. Vascular Anatomy
• Immature
• Variable
– Ligamentum teres
– Metaphyseal circulation
– Lateral epiphyseal vessels (bypass physis)
• Vulnerable to injury

9. Mechanism
• MVC, car vs. ped, high falls
• Minor trauma can still be a cause

10. Classification
Delbet 1928

11. Literature
• Ratliff. BrJBJS, 1962: 71 cases in England
followed for 5 yrs.
• Lam. JBJS, 1972: 75 fractures, 60 acute.
Hong Kong. Follow up 5 yrs.
• Canale and Bourland. JBJS, 1977: 61 cases
at the Campbell Clinic followed for 17 yrs.

12. Type I

14. Type I
• Very rare
• Little evidence
• Can we improve results?

15. Type I
• Nondisplaced  Spica
• Displaced
– past--closed reduction and spica, ORIF
– present--closed or open reduction plus IF
• threaded pins, cannulated screws, smooth pins
– Forlin, JPO 1992: non-op

16. Type I
• With dislocation
– CT
– One attempt closed
– Approach dictated by dislocation

17. Type I
• RESULTS
• Generally poor
• Catastrophic with concurrent dislocation

18. Type II

19. Type II
• Most common type (50% of peds hip fx)
• Most common AVN (50%)
• 3/4 will be displaced

20. Type II
• IF is treatment of choice currently
ND/min.
displaced
displaced
Lam Cast Mystery
Ratliff Cast IF
Canale IF IF

21. Type II
• Treatment
– If cast elected, follow closely
– If in doubt, treat as displaced
– Traction, abduction, IR
– Cannulated screws
– Avoid physis, but stability is first priority

22. Type II
• Treatment
– May require open reduction
– Adequate reduction

23. Type II
• Results
• Nondisplaced  Less complications
• Outcome in literature is variable
• Highest complication rate of the 4 types
• Improved with IF

24. Type III

25. Type III
• Second most common (35% of peds hip fx)
• Second highest AVN rate (25-30%)
• 2/3 will be displaced

26. S.E.--Injury
• 6 yo
• MVC
• Liver laceration
• Ipsilateral femoral
neck, femur, and tibia
fractures

27. S.E.--Injury

28. S.E.--OR (hosp. day 2)

29. S.E.--OR

30. S.E.--OR

31. S.E.--Follow Up
•8 wks post-op:
• Union
• No AVN
• Cast removed, WBAT

32. Type III
ND/min.
displaced
displaced
Lam Cast Mystery
Ratliff Cast IF
Canale Cast IF

33. Type III
• Treatment
– Nondisplaced:
• cast
• follow closely for loss of reduction
– Displaced:
• IF
• cannulated screws or peds hip screw
• avoid physes

34. Type III
• Results
• Similar to type II
• Nondisplaced  Less complications
• Outcome in literature is variable
• IF reduces coxa vara and nonunion

35. M.H.--1 Year f/u
Type III, emergent open reduction (capsulotomy),
Richards ped hip screw

36. Type III

37. Type IV

39. Type IV
• Not common (10-15% of peds hip fx)
• Fewest complications
• AVN still possible, but unusual

40. Type IV
• Treatment
• Most agreement between authors
• Conservative

41. Type IV
• Treatment
• Spica in younger patients
• Pediatric hip screw in older pts, or those
with unstable reduction

42. Type IV
• Results
• Generally good
• Fewest complications

43. R.K.R.--14 yo Male

44. R.K.R.--ORIF, Tape

45. R.K.R.-9 Wks

46. R.K.R.--9 Months

47. R.K.R.--10 mo, ROH

48. R.K.R.--15 Months

49. Type IV--13 yo

50. Type IV --DHS, Wire

51. Type IV--2 Mo Post-op

52. TX Highlights
• # of nondisplaced fractures is small, so
conclusions are difficult
• Most nondisplaced fractures can be treated
in a cast
• Exceptions: older child, type II

53. TX Highlights
• Surgery and implants available now are
different than literature
• More recent emphasis on internal fixation
• Implant depends on age
– <3 smooth pins
– 3-8 4.0 screws, peds hip screw
– 8+ 6.5 screws, peds or adult hip
screw
• Expanded indications in polytrauma pt’s

54. Complications
AVN
Coxa
vara
Physis
closure
Non-
union
Del.
Union
Ratliff 42% 20% 15% 10% 24%
Lam 17% 30% 15% 10%
Canale 43% 21% 62% 6.5%

55. AVN
Most common and devastating
complication

56. AVN
• 40-45% overall rate
• Type I ?, ~100% with dislocation
• Type II 50%
• Type III 25%
• Type IV 10%

57. Type II FNF

58. Type II FNF – 8 and 10 Mos Postop
Posttraumatic Osteonecrosis and Collapse

59. AVN
• Displacement vs. Hematoma

60. AVN--Displacement
• AVN higher in displaced fractures
• Gerber: 30% AVN despite early
capsulotomy
Displaced ND
Ratliff 53% 25%
Canale 52% 8%
Heiser 17% 0%

61. AVN--Hematoma

62. AVN--Hematoma
• Animal studies
• Boitzy: No AVN, 11 type II, early
evacuation
• Swiontkowski and Winquist: 6 displaced II’s
and III’s, CR, capsulotomy, IF. No AVN.
• Pforringer: 6% AVN in displaced type I-III
that were decompressed within 36 hrs

63. AVN--Hematoma
• Ng, Cole. Injury,1996:
• 7/23 (30%) in displaced, 2/9 (22%) in ND
• Displaced II’s and III’s:
– 6 not decompressed, 3/6 AVN
– 10 decompressed, 1/10 AVN
• Literature review: 3/39 (8%) AVN if
decompressed early

64. AVN
Ratliff 1962

65. AVN
• Best form of tx unknown
• Results may be no better
• Maintain motion
• Remove internal fixation

66. COXA VARA
• 20-30% incidence
• Loss of reduction, closure of proximal
femoral physis
• Incidence and amount of deformity
decreased by internal fixation
• Gait abnormalities, degeneration
• Tx: subtrochanteric osteotomy

67. Nonunion
• 5-10% incidence
• Less with internal
fixation
• Treated by valgus
osteotomy, bone
graft, or both

68. Physeal Closure
• Variable incidence
• Causes: AVN, implants, stimulation
• Leg length discrepancy often not
significant, worse with AVN
• Tx: contralateral distal femoral
epiphyseodesis

69. Summary
• Determine Delbet type and displacement
• Treatment and implant will also be
dependent on age
• Urgent decompression has theoretical
advantages

70. Summary
• Nondisplaced fractures will have less
complication and will do better regardless
of treatment.

71. Summary
• Internal fixation is indicated in:
– Displaced type I
– All type II
– Types III and IV if displaced or child is older
– Polytrauma
• Internal fixation may reduce complications

72. Summary
• The more proximal the fx, the more likely
to get AVN
• Complication rate is high. Counsel the
family.

73. Hip Dislocations in
Pediatric Patients
• Uncommon injury, but more common than
femoral neck fractures in children
• Usually posterior
• Less commonly associated with fractures
than adults
• Results better than in adults Still potential
for osteonecrosis and poor outcome

74. Hip Dislocations
• Urgent reduction, closed
• Adequate anesthesia,
relaxation
• Careful assessment of
congruity of reduction
• If uncertain consider CT
scan to rule out
intraarticular fragments
• Open reduction for failure
to reduce closed,
incomplete reduction with
interposed bone or soft
tissue
• Protected weightbearing
following reduction until
full, painless ROM

75. Incarcerated Fragment
Post Reduction

76. Hip Dislocations
• Osteonecrosis rate may be decreased by
prompt reduction
• 8-10% incidence after dislocation in
skeletally immature
• Delay in reduction, high energy mechanism,
and older age are risk factors
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