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

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

“Hip fractures in children are of interest because of the frequency of complications rather than the frequency of fractures.”

Canale

Femoral Neck Fractures in Children

Rare fracture Anatomic and vascular differences Emergent treatment High complication rate

Background

Different from Adults– High-energy

– Thick periosteum

– Vascularity

– Physes

– Treatment options

Background

Osseous Anatomy– Proximal femoral

physis

– Trochanteric apophysis

– Dense bone

– Small neck

Background

Vascular Anatomy– Immature

– Variable Ligamentum teres Lateral epiphyseal

vessels (bypass physis) Metaphyseal

circulation (after physeal closure)

– Vulnerable to injury

Mechanism

MVC Auto-ped High falls Minor trauma can still be a cause

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.

Type ITransepiphyseal

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):431–443.

Type ITreatment

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):164–168.

Type IResults

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):973–977.

Type IExample

10 yr female Type I fracture-

dislocation of hip

Type IExample

ORIF and Pins Attempted

Type IExample

Postop film Malreduced and

dislocated

Type IExample

Repeat ORIF

Type IExample

3 month follow-up

Type IExample

8 Months Heterotopic ossification evident

Type IExample

11 Months Osteonecrosis

Type IITranscervical

Type II

Most common type (50% of peds hip fx)

Most common AVN (50%)

3/4 will be displaced

Type II

Historical treatment Internal fixation is currently the treatment

of choiceLam. Fractures of the neck of the femur in children. J Bone Joint Surg Am. 1971;53:1165–1179. Ratliff. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962;44-B:528–542.Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg Am. 1977;59:431–443.Quick. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;(432):87–96.

Type IITreatment

Nondisplaced– Spica cast, if young

– Use internal fixation, if older

– If in doubt, treat as displaced

Type IITreatment

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

Type IIResults

Nondisplaced– Fewer complications

Outcome in literature is variable– AVN in up to 50%

Highest complication rate of the 4 types

Improved with internal fixation

İnan U, Köse N, Ömeroğlu H. Pediatric femur neck fractures: a retrospective analysis of 39 hips. J Child Orthop. 2009 May 26;3(4):259–264.

Type IIICervicotrochanteric

Type III

Second most common– 35% of peds hip fx

Second highest AVN rate– 25-30%

2/3 displaced


Type IIITreatment

Nondisplaced – Spica cast

– Follow closely for loss of reduction

Displaced ORIF

– Cannulated screws

– Peds hip screw Avoid physes


Type IIIResults

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;84:108–112.

Type IIIExample

6 year old femal MVC Liver laceration Ipsilateral femoral

neck, femur, and tibia fractures

Type IIIExample

Type IIIExample

8 wks post-op Union Cast removed,

WBAT No AVN

Type IVIntertrochanteric

Type IV

Not common – 10-15% of peds hip fx

Fewest complications AVN still possible,

but unusual

Type IVTreatment

Most agreement between authors

Nondisplaced– Hip-spica in younger

patients Displaced

– Pediatric hip screw in older pts

– Or in those with unstable reduction

Type IVResults

Generally good Fewest complications

– High energy still can result in AVN (10-20%)

Type IVExample

14 year old male Motorcycle crash

Type IVExample

Type IVExample

9 weeks post-op

Type IVExample

9 months post-op

Type IVExample

10 months post-op After hardware removal

Type IVExample

15 months post-op AVN

Hip FractureTreatment Highlights

Data on nondisplaced fractures is limited– Conclusions are difficult

Most nondisplaced fractures can be treated in a cast

Exceptions– Older child– Type II

Hip FractureTreatment 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 pt’s

Hip FractureComplications

Lam. Fractures of the neck of the femur in children. J Bone Joint Surg Am. 1971;53:1165–1179. Ratliff. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962;44-B:528–542.Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg Am. 1977;59:431–443.

Hip FractureAVN

Most common and devastatingcomplication

Hip FractureAVN

6 – 53% overall rate

Type I 57% to 100%

Type II 50% Type III 25% Type IV 10%

Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:87–96.

Hip FractureAVN

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


Hip FractureAVN

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


AVNClassification

Ratliff 1962Ratliff A. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962 Aug.;44-B:528–542.

AVNRisk 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.

AVNRisk 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.

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):442–445.

Nonunion

5-10% incidence Less with internal

fixation Treatment

– Valgus osteotomy

– Bone graft

-Bagatur. Complications associated with surgically treated hip fractures in children. J Pediatr Orthop B. 2002;11:219. -Quick. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:87.

Physeal Closure

Variable incidence (up to 40%) Causes: AVN, implants, stimulation Leg length discrepancy often not

significant, worse with AVN Tx: Contralateral distal femoral

epiphysiodesis

-Morsy. Complications of fracture of the neck of the femur in children. A long-term follow-up study. Injury. 2001;32:45.

Summary

Determine Delbet type and displacement Urgent treatment with reduction and

fixation as needed Treatment and implant will also be

dependent on age Joint decompression has theoretical

advantages, and some literature support but quality of evidence poor

Summary

Nondisplaced fractures will have fewer complications and will do better regardless of treatment.

The more proximal the fx, the more likely to get AVN

Complication rate is high. Counsel the family.

Summary

Internal fixation is indicated in:– Displaced type I– All type II– Types III and IV if displaced or child is older– Polytrauma

Internal fixation may reduce complications

Hip Dislocations

Uncommon, but more common than femoral neck fractures in children

Usually posterior, rarely anterior Less commonly associated with fractures than

adults Results better than in adults Still potential for osteonecrosis and poor

outcome

Herrera-Soto. Traumatic hip dislocations in children and adolescents: pitfalls and complications. J Am Acad Orthop Surg. 2009;17:15.

Hip Dislocations

Urgent reduction, closed Adequate anesthesia,

relaxation Careful assessment of

congruity of reduction If uncertain consider

CT/MRI to rule out intra-articular fragments

Protected weight-bearing following reduction until full, painless ROM

Hip DislocationsTreatment

Operative indications

– Delayed treatment

– Irreducible dislocation

– Incongruous or incomplete reduction with interposed bone or soft tissue

Open Reduction Approaches

– Anterior (Smith-Peterson)– Anterolateral (Watson-Jones)– Trans-trochanteric

Avoid posterior to prevent damage to the blood-vessels and potentially-preserved vascularity of the femoral head Trochanteric flip approach

Hip DislocationsTreatment

Hip DislocationsComplications

Complications– Avascular necrosis (8-20%)

– Myositis ossificans (8-15%)

– Sciatic nerve palsy

– Early secondary arthritis

Factors predisposing to poor result:– Older child

– Severe trauma

– Delay in reduction (> 8 hours)

– Incongruous reduction

– AVN


Hip DislocationsSummary

Early diagnosis and prompt reduction Important to recognize associated fracture/

inadequate reduction Advanced imaging may be necessary Surgical approach should not further

compromise blood supply AVN is still a significant risk with 8-20%

incidence in skeletally immature Delay in reduction, high energy mechanism, and

older age are risk factors


Hip DislocationsExample 1


After anterolateral open reduction


12 yr male with reduced hip dislocation and increased medial joint space


Inadequate reduction due to interposition


Open surgical dislocation: Trochanteric flip approach


Intra-articular loose tissue (post-labral piece)


6 month follow-up


15 month follow-up. No evidence of AVN.

Bibliography Bagatur AE, Zorer G. Complications associated with surgically treated hip fractures in children. J

Pediatr Orthop B. 2002 Jul.;11(3):219–228. 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):431–443. Cheng JC, Tang N. Decompression and stable internal fixation of femoral neck fractures in children

can affect the outcome. J Pediatr Orthop. 1999 Apr.;19(3):338–343. Colonna PC. Fractures of the neck of the femur in children. Am J Surg 1929;6:793-7. Eberl R, Singer G, Ferlic P, Weinberg AM, Hoellwarth ME. Post-traumatic coxa vara in children

following screw fixation of the femoral neck. Acta Orthop. 2010 Aug.;81(4):442–445. Flynn JM, Wong KL, Yeh GL, Meyer JS, Davidson RS. Displaced fractures of the hip in children.

Management by early operation and immobilisation in a hip spica cast. J Bone Joint Surg Br. 2002 Jan.;84(1):108–112.

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):164–168.

Herrera-Soto JA, Price CT. Traumatic hip dislocations in children and adolescents: pitfalls and complications. J Am Acad Orthop Surg. 2009 Jan.;17(1):15–21.


Lam SF. Fractures of the neck of the femur in children. J Bone Joint Surg Am. 1971 Sep.;53(6):1165–1179.

Bibliography Mirdad T. Fractures of the neck of femur in children: an experience at the Aseer Central Hospital,

Abha, Saudi Arabia. Injury. 2002 Nov.;33(9):823–827. Morsy HA. Complications of fracture of the neck of the femur in children. A long-term follow-up

study. Injury. 2001 Jan.;32(1):45–51. Ng GP, Cole WG. Effect of early hip decompression on the frequency of avascular necrosis in

children with fractures of the neck of the femur. Injury. 1996 Jul.;27(6):419–421. Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop

Relat Res. 2005;(432):87–96. Ratliff A. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962 Aug.;44-B:528–

542. 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. J Bone and Joint Surg. 2010 Apr.;92(4):973–977.

Shrader MW, Jacofsky DJ, Stans AA, Shaughnessy WJ, Haidukewych GJ. Femoral Neck Fractures in Pediatric Patients. Clin Orthop Relat Res. 2007 Jan.;454:169–173.

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