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Updated: Mar 1 2023

Proximal Femur Fractures - Pediatric

4.3

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Images
https://upload.orthobullets.com/topic/4018/images/Intertrochanteric - colorado_moved.png
https://upload.orthobullets.com/topic/4018/images/type i.jpg
https://upload.orthobullets.com/topic/4018/images/type ii.jpg
https://upload.orthobullets.com/topic/4018/images/type iii.jpg
https://upload.orthobullets.com/topic/4018/images/type iv.jpg
  • summary
    • Proximal Femur Fractures in the pediatric poplulation are rare fractures caused by high-energy trauma and are often associated with polytrauma.
    • Diagnosis can be made with plain radiographs of the hip. 
    • 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
  • Etiology
    • 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
  • 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 (L4, L5, S1)
        • 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
      • Description
      • Incidence
      • AVN
      • Nonunion
      • 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
      • most common complication
      • risk factors
        • age
          • risk increases 1.14 times for every year of increasing age
        • fracture type
          • highest risk with type I (transphyseal) 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
  • Prognosis
    • Poor functional outcomes have been associated with
      • head trauma
      • amputation
      • peripheral neurological damage
      • AVN
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