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Average 4.1 of 49 Ratings
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?
Time to definitive surgical procedure has no effect on outcome
Open reduction with capsular decompression is contraindicated
Internal fixation with a cephalomedullary nail leads to higher union rates than screw fixation
Nonunion is the most common complication if surgical intervention is performed
Closed reduction and cannulated screw fixation across the physis is an acceptable form of surgical management
Select Answer to see Preferred Response
Figure A shows a displaced, transcervical fracture of the femoral neck. Transphyseal screw fixation provides the most reliable fracture stability and is recommended for treatment of most children’s hip fractures (age >6) despite the secondary effect of premature physeal closure.
Femoral neck fractures in children are a rare occurrence with potentially devastating complications. Delbet classifies pediatric femoral neck fractures as follows: type 1) transphyseal, type 2) transcervical, type 3) basicervical, and type 4) intertrochanteric. Treatment for type 2 fractures includes cannulated screw fixation with or without a capsular decompression. The benefits of capsular decompression remain controversial, with some arguing decreased rates of AVN if performed.
Song et al. reviewed 27 femoral neck fractures in children younger than 16. 15 were treated with open reduction and internal fixation (including capsulotomy and reduction under direct visualization) and 12 were treated with closed reduction and internal fixation (CRIF). When compared to CRIF, ORIF provided a more anatomic reduction and a decreased rate of avascular necrosis.
Hajdu et al. reviewed the results of 8 children (age <16) with proximal femur fractures treated surgically. 5 of the 8 had an acute slipped capital femoral epiphysis, 2 had a basicervical femoral neck fracture, and 1 had an intertrochanteric fracture. One of the patients who had an acute slipped capital femoral epiphysis developed AVN, and it was the only patient in the series operated on 48 hours after the injury. They stress the importance of early surgical fixation.
Illustration A shows the Delbet classification of femoral head/neck fractures in children.
Answer 1: Surgical treatment within 48 hours has been shown to decrease rates of osteonecrosis.
Answer 2: Capsular decompression is not contraindicated, and is favored by some surgeons.
Answer 3: Internal fixation with cannulated screws is the preferred method of treatment.
Answer 4: Osteonecrosis is the most common complication following surgical fixation.
J Bone Joint Surg Br. 2010 Aug;92(8):1148-51. PMID: 20675763 (Link to Abstract)
Song, BJJ 2010
Hajdu S, Oberleitner G, Schwendenwein E, Ringl H, VÃ©csei V
Int Orthop. 2011 Jun;35(6):883-8. PMID: 20490791 (Link to Abstract)
Hajdu, INTORT 2011
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Average 2.0 of 18 Ratings
What is the most common complication following surgical fixation for the fracture shown in Figure A in an 8-year-old boy?
Clinically significant limb length discrepancy
The radiograph demonstrates a pediatric basicervical femoral neck fracture. Femoral neck fractures in the pediatric population are associated with a high rate of osteonecrosis. They are divided into epiphyseal, transcervical, basicervical and intertrochanteric. Fracture displacement, age over ten years and an epiphyseal or transcervical fracture pattern are risk factors for AVN.
Moon et al found the rates of AVN were as follows: Delbet type I=38%, II=28%, III=18%, and IV=5%, where I=Epiphyseal, II=Transcervical, III=Basicervical, IV=Intertrochanteric.
Hughes et al discussed several complications. Coxa vara, not coxa valga, occurs about 20-30% of the time and is more common in fractures treated nonoperatively.
Chondrolyis has been reported sporadically, but is always found concomitantly with AVN. Stiffness is not commonly seen after surgical fixation. Premature physeal closure can occur with or without surgery but because the femoral head epiphysis is only responsible for 13% of the ultimate length of the femur, growth disturbances rarely result in limb length discrepancies exceeding 2 cm. If displaced, the fracture requires open reduction, hematoma evacuation and internal fixation with pins. Whether or not the pins should cross the physis is still subject to debate.
Moon ES, Mehlman CT
J Orthop Trauma. 2006 May;20(5):323-9. PMID: 16766935 (Link to Abstract)
Moon, JOT 2006
Hughes LO, Beaty JH.
J Bone Joint Surg Am. 1994 Feb;76(2):283-92. PMID: 8113267 (Link to Abstract)
Hughes, JBJS 1994
Average 3.0 of 28 Ratings
HPI - Pain and weakness right hip during last two years. Limping gait since 10 years old but was doing very well.
What was the most likely cause of his hip dislocation and deformation?