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Introduction
  • Overview
    • pediatric proximal femur fractures are rare fractures caused by high-energy trauma and are often associated with polytrauma
      • closed reduction and definitive treatment is urgent to avoid complications of osteonecrosis, nonunion, and premature physeal closure
      • treatment is usually operative with the technique depending on the age of the patient and the Delbet classification type of fracture
  • Epidemiology
    • incidence
      • accounts for < 1% of pediatric fractures
    • demographics
      • males more commonly affected 2.5:1
      • bimodal distribution
        • children < 2-3 years old due to non-accidental trauma
        • adolescents involved in motor vehicle accidents
  • Pathophysiology
    • mechanism of injury
      • usually results from high-energy trauma (75-80%)
      • can result from low-energy trauma if the patient has weakened bone (i.e. tumors, metabolic bone disease)
  • Associated conditions
    • 30-85% of patients will have associated traumatic injuries
      • head or facial trauma
      • splenic lacerations
      • retroperitoneal hemorrhage
      • perineal injury
      • pelvic ring or acetabular fractures
      • hip dislocation
      • femur fractures
    • associated complications
      • AVN
      • premature physeal closure
  • Prognosis
    • poor functional outcomes have been associated with
      • head trauma
      • amputation
      • peripheral neurological damage
      • AVN
Anatomy
  • Osteology
    • proximal femur develops from 2 centers of ossification
      • proximal femoral epiphysis
        • ossification begins at 4-6 months in girls and 5-7 months in boys
        • responsible for metaphyseal growth of femoral neck
        • rate of growth is 3 mm/year
          • accounts for 13-15% of overall leg length
          • accounts for 30% of overall femur length
      • trochanteric apophysis
        • ossification begins at 4 years in both girls and boys
        • responsible for appositional growth of greater trochanter
          • also makes small contribution to growth of femoral neck and intertrochanteric femur
        • 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 
  • Blood supply 
    • medial femoral circumflex artery (MFCA) 
      • via the posterosuperior and posteroinferior retinacular branches  
      • at birth, contributes to the blood supply to the head with the LFCA and artery of ligamentum teres
      • at 4 years old, becomes the main blood supply after regression of the LFCA and artery of ligamentum teres
    • lateral femoral circumflex artery (LFCA)
      • at birth, contributes to the blood supply to the head
      • regresses in late childhood 
    • artery of the ligamentum teres
      • at birth, contributes to the blood supply to the head
      • diminishes after 4 years old
    • metaphyseal vessels
      • also contribute to blood supply to the head < 3 years old and after 14-17 years
        • between 3 to 14-17 years, the physis blocks metaphyseal supply
        • after 14-17 years, anastomoses between metaphyseal-epiphyseal vessels develop
  • Neurovascular
    • superior gluteal nerve (L5, S1, S2)  
      • gluteus medius 
      • gluteus minimus   
Presentation
  • Symptoms
    • severe pain in affected hip
    • inability to bear weight
  • Physical exam
    • shortened, externally rotated lower extremity
Classification
 
Delbet Classification  
 Type Description Incidence AVN Nonunion  Images
Type I Transphyseal (with or without epiphyseal dislocation) <10%
38%-100%     
Type II Transcervical 40-50%
28% 15%   
Type III Cervicotrochanteric (or basicervical) 30-35% 18% 15-20%   
Type IV Intertrochanteric 10-20% 5% 5%   
 
Imaging
  • Radiographs
    • recommended views
      • AP
      • cross-table lateral
    • optional views
      • bone survey if suspected non-accidental trauma
    • findings
      • break/offset of bony trabeculae near Ward triangle
        • indicates nondisplaced or impacted fracture
  • CT
    • indications
      • nondisplaced fractures and stress fractures
  • MRI
    • indications
      • nondisplaced fractures and stress fractures (preferred over CT)
      • pathologic fractures
    • findings
      • well-defined low-signal line and surrounding high-signal bone edema on T2-weighted images
  • Ultrasound
    • indications
      • nondisplaced fractures in infants
    • findings
      • hemarthrosis
        • difficult to differentiate from effusion due to inflammation or infection
      • subtle epiphyseal mobility
Differential
  • Legg-Calve-Perthes disease
  • Toxic synovitis
  • Spontaneous hemarthrosis
  • Infection
Treatment
  • Nonoperative
    • closed reduction and spica abduction casting 
      • indications (rarely indicated)
        • Type I without epiphyseal dislocation, II, III, IV IF nondisplaced/minimally displaced AND < 4 years old
          • evaluate type I fractures for non-accidental trauma if young (< 2-3 years old)
  • Operative 
    • emergent ORIF with capsulotomy (or joint aspiration)
      • indications
        • open hip fractures (rare)
        • vessel injury where large vessel repair is required (rare)
        • concomitant hip or epiphyseal dislocations (especially type I)
        • fractures with significant displacement 
          • some data suggests this may decrease the rate of AVN
    • closed reduction percutaneous pinning (CRPP)
      • indications
        • type I (without epiphyseal dislocation), II, III if displaced and/or > 4 years old
      • fixation
        • smooth pins may be adequate in young patients if postoperative spica casting performed
        • cannulated screws in older patients and adolescents
      • postop
        • fracture brace or spica cast if there is concern that the long lever arm of the leg could contribute to loss of fixation of the fracture
    • ORIF with pin/screw fixation
      • indications
        • type I II, III if unable to achieve closed anatomic reduction
      • postop
        • consider fracture brace or spica cast if concern for stability of fracture
    • ORIF with sliding hip screw (DHS)
      • indications
        • type IV if displaced or > 4 years old
Techniques
  • Closed reduction and spica abduction casting
    • timing of reduction
      • early reduction (< 24h) may diminish risk of AVN by restoring blood flow through kinked vessels
    • technique
      • fracture table (preferred for most patients)
        • can use radiolucent table for younger patients
      • apply gentle longitudinal traction with abduction and internal rotation
      • follow with weekly radiographs for 3 weeks to make sure reduction maintained
    • acceptable alignment
      • type II
        • accept < 2mm cortical translation, < 5° of angulation, no malrotation
      • type III and IV
        • accept < 10° of angulation
  • Emergent ORIF with capsulotomy (or joint aspiration)
    • may decrease AVN
    • technique
      • aspiration with large bore needle through subadductor/anterior hip approach
      • open capsulotomy through anterior incision
  • Closed reduction and percutaneous pinning (CRPP)
    • reduction technique
      • see above
    • instrumentation
      • smooth or threaded pins/K wires
        • indications
          • type I without epiphyseal dislocation, II, III in patients < 4yrs
      • cannulated screws  
        • indications
          • type I without epiphyseal dislocation, II, III in patients > 4yrs
    • technique
      • pin/screw placement
        • short of the physis
          • indications
            • patients < 4-6yrs
            • most type III fractures
          • less stable than transphyseal
        • transphyseal
          • indications
            • older patients close to skeletal maturity (> 12yrs old)
            • when there is little metaphyseal bone available
            • where crossing the physis is necessary to achieve stable fixation
              • it is easier to treat leg length discrepancy from premature physeal closure than nonunion
          • place within 5mm of subchondral bone
          • avoid anterolateral quadrant of epiphysis and posterior perforation of femoral neck
            • to prevent injury to vasculature
      • postop immobilization
        • post-op spica casting (abduction and internal rotation) for 6-12 weeks if < 4yrs or pin/screw placement short of the physis
          • long lever arm of the leg could contribute to loss of fixation of the fracture
  • ORIF with pin/screw fixation 
    • approach
      • anterolateral (Watson-Jones)
    • instrumentation/technique
      • see above
  • ORIF with DHS
    • approach
      • lateral (Hardinge)
    • instrumentation 
      • pediatric hip screw
Complications
  • AVN  
    • most common complication
    • risk factors
      • age 3-8 years
      • fracture type
        • highest for type I fractures (nearly 100% if epiphyseal dislocation)   
      • delayed reduction > 24 hours
      • inadequate/unstable reduction
    • etiology
      • kinking/laceration of vessels
      • tamponade by intracapsular hematoma
    • classification - Ratliff
      • type I - involvement of whole head
      • type II - partial involvement of head
      • type III - area of necrosis in femoral neck from fracture line to physis
    • treatment
      • core decompression
      • vascularized fibular graft
  • Coxa vara (neck-shaft angle <120°)
    • 2nd most common complication
    • risk factors
      • more common if fracture is treated non-operatively
      • more common for type I, II and III fractures
        • incidence 25% for type III
    • treatment
      • young patients (0-3 yrs) will remodel if neck-shaft angle > 110°
      • surgical arrest of trochanteric apophysis
        • indications
          • mild coxa vara in < 6-8 yrs
            • only works in younger patients
      • subtrochanteric or intertrochanteric valgus osteotomy
        • indications
          • coxa vara with nonunion  
          • coxa vara with severe Trendelenburg limp or signs/symptoms of FAI
          • older patients
  • Coxa valga
    • seen in type IV fractures involving GT in younger patients
      • due to premature GT apophysis closure
  • Nonunion   
    • can occur together with coxa vara (see above)
    • etiology
      • nonoperative treatment of type II or III fractures
      • occult infection at fracture site
      • malreduced fracture
    • treatment
      • ORIF and immobilization (spica cast if younger patient)
      • subtrochanteric or intertrochanteric valgus osteotomy
      • bone grafting if persistent
  • Physeal arrest 
    • can lead to leg length discrepancy
      • proximal femoral physis contributes to 15% of overall limb length (3 mm/yr)
      • significant (> 2cm) leg length discrepancy is rare and only occurs in very young children
    • risk factors
      • penetration of physis by fixation devices
      • AVN
        • more common in patients with type II or III AVN
  • Limb length discrepancy (LLD)
    • significant LLD occurs in combined AVN and physeal arrest
    • treatment
      • shoe lift if projected LLD at skeletal maturity is < 2cm
      • epiphysiodesis of contralateral distal femur ± proximal tibia if projected LLD at skeletal maturity is 2-5cm
  • Chondrolysis
    • usually associated with AVN
    • etiology
      • poor vascularity to femoral head cartilage
      • penetration of hardware into joint
    • presents as restricted hip motion, hip pain, radiographic joint space narrowing
  • Malreduction
    • common with subtrochanteric fractures 
      • deforming forces lead to proximal fragment in flexion, abduction, and external rotation
  • Infection
 

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(OBQ12.224) A 13-year-old female falls and sustains the injury shown in Figure A. Which of the following statements is true regarding the treatment of this condition? Review Topic

QID: 4584
FIGURES:
1

Time to definitive surgical procedure has no effect on outcome

3%

(99/3915)

2

Open reduction with capsular decompression is contraindicated

2%

(65/3915)

3

Internal fixation with a cephalomedullary nail leads to higher union rates than screw fixation

7%

(261/3915)

4

Nonunion is the most common complication if surgical intervention is performed

14%

(532/3915)

5

Closed reduction and cannulated screw fixation across the physis is an acceptable form of surgical management

75%

(2919/3915)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ06.113) What is the most common complication following surgical fixation for the fracture shown in Figure A in an 8-year-old boy? Review Topic

QID: 299
FIGURES:
1

Coxa valga

5%

(28/543)

2

Chondrolysis

3%

(14/543)

3

Stiffness

3%

(18/543)

4

Clinically significant limb length discrepancy

5%

(25/543)

5

Avascular necrosis

84%

(455/543)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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