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Introduction
  • Overview
    • challenging because of the high rates of complications 
      • AVN
      • coxa vara malunion
  • Pathophysiology
    • mechanism
      • high energy trauma (75-80%)
      • Type I can occur in newborns after breech delivery
        • similar to Salter Harris I injury
  • Prognosis
    • timing of treatment impact prognosis
      • Delbet type I to III are surgical emergencies
Anatomy
  • Growth centers of the proximal femur
    • 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 
  • Vascularity 
    • 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
  • Neurovacular
    • superior gluteal nerve (L5, S1, S2)  
      • gluteus medius   and gluteus minimus  
Classification
 
Delbet Classification  
 Type Description Incidence AVN Nonunion  Images
Type I Transphyseal (IA, without dislocation of epiphysis from acetabulum; IB, with dislocation of epiphysis) <10%
38% (AVN 100% in type IB)     
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
    • AP pelvis and cross-table lateral
  • CT
    • for nondisplaced fractures and stress fractures
  • MRI
    • for nondisplaced fractures and stress fractures
Treatment
  • Nonoperative
    • spica cast in abduction, weekly radiographs for 3wks
      • indications
        • Type IA, II, III, IV, nondisplaced, <4yrs
          • evaluate Type IA fractures for child abuse
          • rare 
          • only seen in young children
  • Operative 
    • emergent ORIF, capsulotomy, or joint aspiration
      • indications
        • open hip fracture (rare)
        • vessel injury where large vessel repair is required (rare)
        • concomitant hip dislocation (especially type I)
        • significant displacement 
          • some data suggests this may decrease the rate of AVN
    • closed reduction internal fixation (CRIF)/ percutaneous pinning (CRPP) with cannulated screws
      • indications
        • Type I,II,III displaced
          • postop spica (abduction and internal rotation) x 6-12wk
    • open reduction and internal fixation (ORIF)
      • indications
        • Type IB
    • pediatric hip screw / DHS screws/ compression screw
      • indications
        • Type IV
Techniques
  • Emergent reduction and capsulotomy 
    • timing of reduction
      • early reduction (<24h) may diminish risk of AVN by restoring blood flow through kinked vessels
    • reduction technique
      • radiolucent table for 0-10 years
      • fracture table for >10 years
    • acceptable alignment
      • Type II
        • accept <2mm cortical translation, <5° of angulation, no malrotation
      • Type III and IV
        • accept <10° of angulation
    • capsulotomy
      • may decrease AVN
      • 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
    • fixation
      • smooth or threaded pins / K wires (use 2-3 pins or wires)
        • indications
          • younger patients
          • transphyseal
            • recommended when there is little metaphyseal bone available
      • cannulated screws    
        • indications 
          • short of the physis
            • less stable than transphyseal
            • for patients <4-6yrs
          • transphyseal 
            • older patients close to skeletal maturity (>12yrs old)
            • 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
  • Closed reduction and internal fixation (CRIF)
    • indications
      • type IV
      • appropriate if immediately available
    • implants
      • pediatric hip screws   
  • Open reduction and internal fixation (ORIF)
    • approach
      • anterolateral (Watson-Jones) for types I, II, III
      • lateral (Hardinge) for type IV
Complications
  • AVN  
    • most common complication
      • risks = age +  fracture type
        • most susceptible age = 3-8 years
        • highest for Delbet type I (nearly 100% for Delbet type IB)   
    • etiology
      • kinking/laceration of vessels
      • tamponade by intracapsular hematoma
    • treatment
      • core decompression
      • vascularized fibular graft
  • Coxa vara (neck-shaft angle <120°)
    • 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
    • treatment
      • young patients (0-3yrs) will remodel
      • surgical arrest of trochanteric apophysis
        • indication
          • coxa vara in <6-8yrs
            • only works in younger patient
      • subtrochanteric or intertrochanteric valgus osteotomy
        • indication
          • coxa vara + nonunion  
          • coxa vara with severe Trendelenburg limp or FAI signs and symptoms
          • for the older patient
  • Nonunion    
    • can occur together with coxa vara (see above)
    • etiology
      • nonoperative treatment of Type II or III
      • occult infection at fracture site
      • malreduced fracture
    • treatment
      • subtrochanteric or intertrochanteric valgus osteotomy
  • Coxa valga
    • Type IV fractures involving GT in younger patient may have premature GT apophysis closure, leading to coxa valga
  • Physeal arrest
    • physeal arrest alone leads to <1.5cm leg length discrepancy
      • only in very young children
      • proximal femoral physis contributes to 15% of limb length (3mm/yr)
  • Limb length discrepancy
    • significant LLD occurs in combined AVN + physeal arrest
    • treatment
      • shoe lift if projected LLD at skeletal maturity <2cm
      • epiphysiodesis of contralateral distal femur ± proximal tibia if projected LLD at skeletal maturity 2-5cm
  • 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
  • Malreduction
    • common with subtrochanteric fractures
      • deforming forces on proximal fragment
        • displaced into flexion, abduction, and external rotation
  • 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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