1. 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

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

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

4. Displaced Femoral Neck Fracture

5. Not Adults High-energy Thick periosteum Vascularity Physes Treatment options

6. Osseous Anatomy Proximal femoral physis Trochanteric apophysis Dense bone Small neck

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

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

10. Classification Delbet 1928

11. 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.

12. Type I

14. 10 yo Female- Injury – Type I Fracture Dislocation of Hip

15. ORIF and Pins Attempted

16. Postop Film- Malreduced and Dislocated

17. CT Prior to Return to OR

18. Repeat ORIF

19. 3 Months

20. 8 Months – Heterotopic Ossification Evident

21. 11 Months - Osteonecrosis

22. Type I Very rare Little evidence Can we improve results?

23. 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

24. Type I RESULTS Generally poor Catastrophic with concurrent dislocation

25. Type II

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

27. Type II IF is treatment of choice currently

28. 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

29. Type II Treatment –May require open reduction –Adequate reduction

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

31. Type II

32. Type III

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

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

35. S.E.-Injury

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

37. S.E.-OR

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

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

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

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

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

44. Type IV

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

47. Type IV Treatment Most agreement between authors Conservative in younger children

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

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

50. R.K.R.-14 yo Male

51. R.K.R.-ORIF, Tape

52. R.K.R.-9 Weeks

53. R.K.R.-9 Months

54. R.K.R.-10 months, ROH

55. R.K.R.-15 months

56. Type IV-13 yo

57. Type IV--DHS, Wire

58. Type IV-2 months post-op

59. 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

60. 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 –3-84.0 screws, peds hip screw –8+6.5 screws, peds or adult hip screw, blade plate Expanded indications in polytrauma pt’s

61. Complications

62. AVN Most common and devastating complication

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

64. Type II FNF

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

66. AVN Displacement vs. Hematoma

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

68. AVN-Hematoma

69. 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

70. 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

71. AVN Ratliff 1962

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

73. 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

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

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

76. 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

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

78. 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

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

80. 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

81. 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

82. 4 year old – fell in yard- dislocated hip- closed reduction and spica NONCONCENTRIC REDUCTION WITH WIDENED APPARENT JOINT SPACE

83. After Anterior Open Reduction and Removal of Interposed Labrum

84. At One Year No Osteonecrosis and Ssymptomatic h.o.

85. Incarcerated Fragment Post Reduction

86. 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 E-mail 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 e-mail to ota@aaos.orgota@aaos.org