summary Proximal Femur Fractures in the pediatric population 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 login to view 5 more bullets trochanteric apophysis login to view 6 more bullets 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 login to view 2 more bullets 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 login to view 1 more bullet 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 login to view 1 more bullet subtle epiphyseal mobility Differential Legg-Calve-Perthes disease Toxic synovitis Spontaneous hemarthrosis Infection Treatment Nonoperative closed reduction and spica abduction casting indications (rarely indicated) login to view 2 more bullets Operative emergent ORIF with capsulotomy (or joint aspiration) indications login to view 5 more bullets closed reduction percutaneous pinning (CRPP) indications login to view 1 more bullet fixation login to view 2 more bullets postop login to view 1 more bullet ORIF with pin/screw fixation indications login to view 1 more bullet postop login to view 1 more bullet ORIF with sliding hip screw (DHS) indications login to view 1 more bullet 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) login to view 1 more bullet 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 login to view 1 more bullet type III and IV login to view 1 more bullet 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 login to view 2 more bullets cannulated screws login to view 2 more bullets technique pin/screw placement login to view 14 more bullets postop immobilization login to view 2 more bullets 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 login to view 1 more bullet fracture type login to view 2 more bullets delayed reduction > 24 hours inadequate/unstable reduction login to view 1 more bullet 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 login to view 1 more bullet treatment young patients (0-3 yrs) will remodel if neck-shaft angle > 110° surgical arrest of trochanteric apophysis login to view 3 more bullets subtrochanteric or intertrochanteric valgus osteotomy login to view 4 more bullets 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 login to view 1 more bullet 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