Fractures and Dislocations about the Hip in the Pediatric Patient Steven Frick, MD Original Author: Mark Tenholder, MD; March 2004 New Author: Steven Frick, MD; Revised August 2006

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

1. Rare Fracture 2. High Complication Rate 3. Emergency?

Displaced Femoral Neck Fracture

Not Adults High-energy Thick periosteum Vascularity Physes Treatment options

Osseous Anatomy Proximal femoral physis Trochanteric apophysis Dense bone Small neck

Vascular Anatomy Immature Variable –Ligamentum teres –Metaphyseal circulation –Lateral epiphyseal vessels (bypass physis) Vulnerable to injury

Mechanism MVC, car vs. ped, high falls Minor trauma can still be a cause

Classification Delbet 1928

Literature Ratliff. BrJBJS, 1962: 71 cases in England followed for 5 yrs. Lam. JBJS, 1972: 75 fractures, 60 acute. Hong Kong. Follow up 5 yrs. Canale and Bourland. JBJS, 1977: 61 cases at the Campbell Clinic followed for 17 yrs.

Type I

10 yo Female- Injury – Type I Fracture Dislocation of Hip

ORIF and Pins Attempted

Postop Film- Malreduced and Dislocated

CT Prior to Return to OR

Repeat ORIF

3 Months

8 Months – Heterotopic Ossification Evident

11 Months - Osteonecrosis

Type I Very rare Little evidence Can we improve results?

Type I Nondisplaced  Spica Displaced –past--closed reduction and spica, ORIF –present--closed or open reduction plus IF threaded pins, cannulated screws, smooth pins –Forlin, JPO 1992: non-op

Type I RESULTS Generally poor Catastrophic with concurrent dislocation

Type II

Most common type (50% of peds hip fx) Most common AVN (50%) 3/4 will be displaced

Type II IF is treatment of choice currently

Type II Treatment –If cast elected, follow closely –If in doubt, treat as displaced –Traction, abduction, IR –Cannulated screws –Avoid physis, but stability is first priority

Type II Treatment –May require open reduction –Adequate reduction

Type II Results Nondisplaced  Less complications Outcome in literature is variable Highest complication rate of the 4 types Improved with IF

Type II

Type III

Second most common (35% of peds hip fx) Second highest AVN rate (25-30%) 2/3 will be displaced

S.E.-Injury 6 yo MVC Liver laceration Ipsilateral femoral neck, femur, and tibia fractures

S.E.-Injury

S.E.-OR (hosp. day 2)

S.E.-OR

S.E.-Follow Up 8 wks post-op: Union No AVN Cast removed, WBAT

Type III Treatment –Nondisplaced: cast follow closely for loss of reduction –Displaced: IF cannulated screws or peds hip screw avoid physes

Type III Results Similar to type II Nondisplaced  Less complications Outcome in literature is variable IF reduces coxa vara and nonunion

M.H.--1 year f/u Type III, emergent open reduction (capsulotomy), Richards ped hip screw

Type III - 8 mos. s/p Fusion for Severe AVN

Type IV

Not common (10-15% of peds hip fx) Fewest complications AVN still possible, but unusual

Type IV Treatment Most agreement between authors Conservative in younger children

Type IV Treatment Spica in younger patients Pediatric hip screw in older pts, or those with unstable reduction

Type IV Results Generally good Fewest complications- high energy still can result in AVN

R.K.R.-14 yo Male

R.K.R.-ORIF, Tape

R.K.R.-9 Weeks

R.K.R.-9 Months

R.K.R.-10 months, ROH

R.K.R.-15 months

Type IV-13 yo

Type IV--DHS, Wire

Type IV-2 months post-op

TX Highlights # of nondisplaced fractures is small, so conclusions are difficult Most nondisplaced fractures can be treated in a cast Exceptions: older child, type II

TX Highlights Surgery and implants available now are different than those used in older literature More recent emphasis on internal fixation Implant depends on age –<3smooth pins – screws, peds hip screw –8+6.5 screws, peds or adult hip screw, blade plate Expanded indications in polytrauma pt’s

Complications

AVN Most common and devastating complication

AVN 40-45% overall rate Type I ?, ~100% with dislocation Type II50% Type III 25% Type IV10%

Type II FNF

Type II FNF – 8 and 10 months postop Posttraumatic osteonecrosis and collapse

AVN Displacement vs. Hematoma

AVN-Displacement AVN higher in displaced fractures Gerber: 30% AVN despite early capsulotomy

AVN-Hematoma

Animal studies Boitzy: No AVN, 11 type II, early evacuation Swiontkowski and Winquist: 6 displaced II’s and III’s, CR, capsulotomy, IF. No AVN. Pforringer: 6% AVN in displaced type I-III that were decompressed within 36 hrs

AVN-Hematoma Ng, Cole. Injury,1996: 7/23 (30%) in displaced, 2/9 (22%) in ND Displaced II’s and III’s: –6 not decompressed, 3/6 AVN –10 decompressed, 1/10 AVN Literature review: 3/39 (8%) AVN if decompressed early

AVN Ratliff 1962

AVN Best form of tx unknown Results may be no better Maintain motion Remove internal fixation

Coxa Vara 20-30% incidence Loss of reduction, closure of proximal femoral physis Incidence and amount of deformity decreased by internal fixation Gait abnormalities, degeneration Tx: subtrochanteric osteotomy

Nonunion 5-10% incidence Less with internal fixation Treated by valgus osteotomy, bone graft, or both

Physeal Closure Variable incidence Causes: AVN, implants, stimulation Leg length discrepancy often not significant, worse with AVN Tx: contralateral distal femoral epiphyseodesis

Summary Determine Delbet type and displacement Treatment and implant will also be dependent on age Urgent 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.

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

Summary The more proximal the fx, the more likely to get AVN Complication rate is high. Counsel the family.

Hip Dislocations in Pediatric Patients Uncommon injury, but more common than femoral neck fractures in children Usually posterior Less commonly associated with fractures than adults Results better than in adults Still potential for osteonecrosis and poor outcome

Hip Dislocations Urgent reduction, closed Adequate anesthesia, relaxation Careful assessment of congruity of reduction If uncertain consider CT scan to rule out intraarticular fragments Open reduction for failure to reduce closed, incomplete reduction with interposed bone or soft tissue Protected weightbearing following reduction until full, painless ROM

4 year old – fell in yard- dislocated hip- closed reduction and spica NONCONCENTRIC REDUCTION WITH WIDENED APPARENT JOINT SPACE

After Anterior Open Reduction and Removal of Interposed Labrum

At One Year No Osteonecrosis and Ssymptomatic h.o.

Incarcerated Fragment Post Reduction

Hip Dislocations Osteonecrosis rate may be decreased by prompt reduction 8-10% incidence after dislocation in skeletally immature Delay in reduction, high energy mechanism, and older age are risk factors Return to Pediatrics Index OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an to