This document discusses proximal femoral fractures in children. It covers the growth centers of the proximal femur and its blood supply. It then classifies proximal femoral fractures using the Delbet classification system and discusses the treatment and complications of these fractures, which include avascular necrosis, coxa vara, non-union, limb length discrepancy, chondrolysis, and infection. It provides details on the incidence, risk factors, evaluation and treatment of each complication.

1. Dr. Muhammad Bilal
Resident Trauma & Orthopedic department
PIMS

2.  Growth centers of proximal femur
 Blood supply of head of femur
 Fracture classification
 Treatment
 Complications

3.  proximal femoral epiphysis
◦ accounts for 13-15% of leg length
◦ accounts for 30% length of femur
◦ proximal femoral physis grows 3 mm/yr
◦ entire lower limb grows 23 mm/yr
 Trochanteric apophysis
◦ Traction apophysis
◦ contributes to femoral neck growth
◦ 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

4.  medial femoral circumflex artery
◦ main blood supply to the head via the posterosuperior lateral epiphyseal
branch and via posteroinferior retinacular branch
◦ becomes main blood supply after 4 years after regression of LFCA and
artery of ligamentum teres
 lateral femoral circumflex artery
◦ regresses in late childhood
 artery of the ligamentum teres
◦ diminishes after 4 years old
 metaphyseal vessels
◦ also contribute to blood supply to the head < 3 years old and after 14-
17years
 between 3 to 14-17 years, the physis blocks metaphyseal supply
 after 14-17 years, anastomoses between metaphyseal-epiphyseal vessels
develop

6. Delbet Classification
Type Description Incidence AVN Nonunion
Type I Transphyseal (IA, without
dislocation of epiphysis from
acetabulum; IB, with dislocation
of epiphysis)
<10% 38%
Type II Transcervical 40-50% 28%
15%
Type III Cervicotrochanteric (or
basicervical)
30-35% 18%
15-20%
Type IV Intertrochanteric 10-20% 5% 5%

11.  Avascular necrosis
 Coxa vara
 Non-union
 Limb length discripency
 Chondrolysis
 Infection

12.  Avascular necrosis
most common complication
◦ most susceptible age for AVN is 3-8 years
◦ risk of AVN is highest for Delbet type I and nearly
100% for Delbet type IB
 etiology
◦ kinking of vessels
◦ laceration of vessels
◦ tamponade by intracapsular hematoma
 treatment
◦ core decompression
◦ vascularized fibular graft

13. COXA VARA (neck-shaft angle <130deg)
 2nd most common complication
 more common if fracture is treated non-
operatively
 more common for types I, II and III
◦ incidence 25% for type III

14. Treatment
 young patients (0-3yrs) will remodel
 surgical arrest of trochanteric apophysis
◦ indication
 coxa vara in <6-8yrs
 subtrochanteric or intertrochanteric valgus
osteotomy
◦ indication
 coxa vara + nonunion

15. NONUNION
 can occur together with coxa vara
 etiology
◦ nonoperative treatment of Type II or III
◦ occult infection at fracture site
◦ severe AVN of proximal femur
 Treatment
◦ subtrochanteric or intertrochanteric valgus
osteotomy

16. Limb length discrepancy
 significant LLD occurs in combined AVN +
physeal arrest
 treatment
◦ shoe lift
 indications
 projected LLD at skeletal maturity <2cm
◦ epiphysiodesis of contralateral distal femur and/or
proximal tibia
 indications
 projected LLD at skeletal maturity 2-5cm

17. Chondrolysis
◦ usually associated with AVN
◦ etiology
 poor vascularity to femoral head cartilage
 persistent hardware penetration of joint
◦ presents as restricted hip motion, hip pain,
radiographic joint space narrowing

18. Infection
 <1% incidence
 after ORIF or CRPP
 treatment
◦ debridement, maintain fixation until union
 may lead to osteomyelitis, AVN, chondrolysis,
premature physeal closure

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