fractures and dislocations about the hip in the pediatric patient joshua klatt, md original author:...

Download Fractures and Dislocations about the Hip in the Pediatric Patient Joshua Klatt, MD Original Author: Mark Tenholder, MD; March 2004 Revised: Steven Frick,

Post on 02-Apr-2015

220 views

Category:

Documents

0 download

Embed Size (px)

TRANSCRIPT

  • Slide 1

Fractures and Dislocations about the Hip in the Pediatric Patient Joshua Klatt, MD Original Author: Mark Tenholder, MD; March 2004 Revised: Steven Frick, MD; August 2006 Harish Hosalkar, MD; April 2011 Joshua Klatt, MD; November 2011 Slide 2 Hip fractures in children are of interest because of the frequency of complications rather than the frequency of fractures. Canale Slide 3 Femoral Neck Fractures in Children Rare fracture Anatomic and vascular differences Emergent treatment High complication rate Slide 4 Background Different from Adults High-energy Thick periosteum Vascularity Physes Treatment options Slide 5 Background Osseous Anatomy Proximal femoral physis Trochanteric apophysis Dense bone Small neck Slide 6 Background Vascular Anatomy Immature Variable Ligamentum teres Lateral epiphyseal vessels (bypass physis) Metaphyseal circulation (after physeal closure) Vulnerable to injury Slide 7 Mechanism MVC Auto-ped High falls Minor trauma can still be a cause Slide 8 Classification Type 1 Transepiphyseal Type 2 Transcervical Type 3 Cervicotrochanteric Type 4 - Intertrochanteric Colonna PC. Fractures of the neck of the femur in children. Am J Surg 1929;6:793-7. Slide 9 Type I Transepiphyseal Slide 10 Type I Very rare Little evidence High risk of AVN (up to 100% in some series) Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg Am. 1977 Jun.;59(4):431443. Slide 11 Type I Treatment Nondisplaced Can treat with spica cast Displaced Past Closed reduction and spica ORIF Present Closed or open reduction plus internal fixation Threaded pins Cannulated screws Smooth pins Forlin E, Guille JT, Kumar SJ, Rhee KJ. Transepiphyseal fractures of the neck of the femur in very young children. J Pediatr Orthop. 1992 Feb.;12(2):164168. Slide 12 Type I Results Recent literature following better understanding of hip vascularity In some circumstances the femoral head may not be completely avascular, and, with appropriate surgical care, the hip can be preserved Schoenecker JG, Kim Y-J, Ganz R. Treatment of traumatic separation of the proximal femoral epiphysis without development of osteonecrosis: a report of two cases. The Journal of Bone and Joint Surgery. 2010 Apr.;92(4):973977. Slide 13 Type I Example 10 yr female Type I fracture- dislocation of hip Slide 14 Type I Example ORIF and Pins Attempted Slide 15 Type I Example Postop film Malreduced and dislocated Slide 16 Type I Example Repeat ORIF Slide 17 Type I Example 3 month follow-up Slide 18 Type I Example 8 Months Heterotopic ossification evident Slide 19 Type I Example 11 Months Osteonecrosis Slide 20 Type II Transcervical Slide 21 Type II Most common type (50% of peds hip fx) Most common AVN (50%) 3/4 will be displaced Slide 22 Type II Historical treatment Internal fixation is currently the treatment of choice Lam. Fractures of the neck of the femur in children. J Bone Joint Surg Am. 1971;53:11651179. Ratliff. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962;44-B:528542. Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg Am. 1977;59:431443. Quick. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;(432):8796. Slide 23 Type II Treatment Nondisplaced Spica cast, if young Use internal fixation, if older If in doubt, treat as displaced Slide 24 Type II Treatment Displaced Anatomic reduction is important, open if necessary Do not accept varus mal- reductions Avoid excess traction Fracture table may be used without extreme positioning for prolonged period Cannulated screws/ threaded pins to compress Avoid physis But stability and reduction is first priority Slide 25 Type II Results Nondisplaced Fewer complications Outcome in literature is variable AVN in up to 50% Highest complication rate of the 4 types Improved with internal fixation nan U, Kse N, merolu H. Pediatric femur neck fractures: a retrospective analysis of 39 hips. J Child Orthop. 2009 May 26;3(4):259264. Slide 26 Type III Cervicotrochanteric Slide 27 Type III Second most common 35% of peds hip fx Second highest AVN rate 25-30% 2/3 displaced nan U, Kse N, merolu H. Pediatric femur neck fractures: a retrospective analysis of 39 hips. J Child Orthop. 2009 May 26;3(4):259264. Slide 28 Type III Treatment Nondisplaced Spica cast Follow closely for loss of reduction Displaced ORIF Cannulated screws Peds hip screw Avoid physes nan U, Kse N, merolu H. Pediatric femur neck fractures: a retrospective analysis of 39 hips. J Child Orthop. 2009 May 26;3(4):259264. Slide 29 Type III Results Slightly better than II Nondisplaced Fewer complications Outcome in literature is variable AVN in up to 30% IF reduces coxa vara and nonunion Flynn. Displaced fractures of the hip in children. Management by early operation and immobilisation in a hip spica cast. J Bone Joint Surg Br. 2002;84:108112. Slide 30 Type III Example 6 year old femal MVC Liver laceration Ipsilateral femoral neck, femur, and tibia fractures Slide 31 Type III Example Slide 32 8 wks post-op Union Cast removed, WBAT No AVN Slide 33 Type IV Intertrochanteric Slide 34 Type IV Not common 10-15% of peds hip fx Fewest complications AVN still possible, but unusual Slide 35 Type IV Treatment Most agreement between authors Nondisplaced Hip-spica in younger patients Displaced Pediatric hip screw in older pts Or in those with unstable reduction Slide 36 Type IV Results Generally good Fewest complications High energy still can result in AVN (10- 20%) Slide 37 Type IV Example 14 year old male Motorcycle crash Slide 38 Type IV Example Slide 39 9 weeks post-op Slide 40 Type IV Example 9 months post-op Slide 41 Type IV Example 10 months post-op After hardware removal Slide 42 Type IV Example 15 months post-op AVN Slide 43 Hip Fracture Treatment Highlights Data on nondisplaced fractures is limited Conclusions are difficult Most nondisplaced fractures can be treated in a cast Exceptions Older child Type II Slide 44 Hip Fracture Treatment Highlights Surgery and implants available now are different than those used in older literature More recent emphasis on internal fixation Anatomic reduction and compression is key for successful union Surgical approach should not further destabilize blood supply to femoral head Expanded indications in polytrauma pts Slide 45 Hip Fracture Complications Lam. Fractures of the neck of the femur in children. J Bone Joint Surg Am. 1971;53:11651179. Ratliff. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962;44-B:528542. Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg Am. 1977;59:431443. Slide 46 Hip Fracture AVN Most common and devastating complication Slide 47 Hip Fracture AVN 6 53% overall rate Type I 57% to 100% Type II50% Type III25% Type IV10% Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:8796. Slide 48 Hip Fracture AVN AVN may develop if The vessels are torn in the initial injury The vessels are kinked at due to displacement There is intracapsular tamponade causing vascular disruption The vessels are not protected during healing Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:8796. Slide 49 Hip Fracture AVN Factors influencing rate of AVN Degree of initial displacement Timing of reduction and fixation Quality of reduction Stability of reduction and fixation Decompression of capsular hematoma Weight-bearing status Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:8796. Slide 50 AVN Classification Ratliff 1962 Ratliff A. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962 Aug.;44-B:528542. Slide 51 AVN Risk Factors Degree of Initial Displacement Nondisplaced None in most series Displaced 43% to 88% rate Timing of reduction Less than 24 hours 0% to 6% Greater than 48 hours 40% -Mirdad. Fractures of the neck of femur in children: an experience at the Aseer Central Hospital, Abha, Saudi Arabia. Injury. 2002;33:823. -Morsy. Complications of fracture of the neck of the femur in children. A long-term follow-up study. Injury. 2001;32:45. -Forlin. Transepiphyseal fractures of the neck of the femur in very young children. J Pediatr Orthop. 1992;12:164. -Cheng. Decompression and stable internal fixation of femoral neck fractures in children can affect the outcome. J Pediatr Orthop. 1999;19:338. -Flynn. Displaced fractures of the hip in children. Management by early operation and immobilisation in a hip spica cast. J Bone Joint Surg Br. 2002;84:108. -Shrader. Femoral Neck Fractures in Pediatric Patients. Clin Orthop Relat Res. 2007;454:169. Slide 52 AVN Risk Factors Quality of reduction Excellent/anatomic reduction 0% to 17% AVN Nonanatomic/fair/poor 70% to 100% AVN Capsular decompression No decompression 50% Decompression 0% to 10% -Morsy. Complications of fracture of the neck of the femur in children. A long-term follow-up study. Injury. 2001;32:45. -Shrader. Femoral Neck Fractures in Pediatric Patients. Clin Orthop Relat Res. 2007;454:169. -Cheng. Decompression and stable internal fixation of femoral neck fractures in children can affect the outcome. J Pediatr Orthop. 1999;19:338. -Ng. Effect of early hip decompression on the frequency of avascular necrosis in children with fractures of the neck of the femur. Injury. 1996;27:419. Slide 53 Coxa Vara 20-50% incidence Loss of reduction, closure of proximal femoral physis Incidence and amount of deformity decreased by internal fixation Gait abnormalities, degeneration Tx: Subtrochanteric osteotomy Eberl. Post-traumatic coxa vara in children following screw fixation of the femoral neck. Acta Orthop. 2010 Aug.;81(4):442445. Slide 54