p08 pediatric hip

Fractures and Dislocations about the Hip

in the Pediatric Patient

Mark Tenholder, MD

• “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

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

• With dislocation– CT– One attempt closed– Approach dictated by dislocation

Type I

• RESULTS• Generally poor• Catastrophic with concurrent dislocation

Type II

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

ND/min.displaced displaced

Lam Cast Mystery

Ratliff Cast IF

Canale IF IF

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 III

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.--OR

S.E.--Follow Up

•8 wks post-op:• Union• No AVN• Cast removed, WBAT

Type III

ND/min.displaced displaced

Lam Cast Mystery

Ratliff Cast IF

Canale Cast IF

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

Type IV

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

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

R.K.R.--14 yo Male

R.K.R.--ORIF, Tape

R.K.R.-9 Wks

R.K.R.--9 Months

R.K.R.--10 mo, ROH

R.K.R.--15 Months

Type IV--13 yo

Type IV --DHS, Wire

Type IV--2 Mo 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 literature• More recent emphasis on internal fixation• Implant depends on age

– <3 smooth pins– 3-8 4.0 screws, peds hip screw– 8+ 6.5 screws, peds or adult hip screw

• Expanded indications in polytrauma pt’s

Complications

AVN Coxavara

Physisclosure

Non-union

Del.Union

Ratliff 42% 20% 15% 10% 24%

Lam 17% 30% 15% 10%

Canale 43% 21% 62% 6.5%

AVN

Most common and devastatingcomplication

AVN

• 40-45% overall rate

• Type I ?, ~100% with dislocation• Type II 50%• Type III 25%• Type IV 10%

Type II FNF

Type II FNF – 8 and 10 Mos Postop

Posttraumatic Osteonecrosis and Collapse

AVN

• Displacement vs. Hematoma

AVN--Displacement

• AVN higher in displaced fractures

• Gerber: 30% AVN despite early capsulotomy

Displaced NDRatliff 53% 25%Canale 52% 8%

Heiser 17% 0%

AVN--Hematoma

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

Summary

• Nondisplaced fractures will have less complication 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

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

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