fractures and dislocations about the hip in the pediatric patient
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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Fractures and Dislocations about the Hip in the Pediatric Patient
Joshua Klatt, MD
Original Author: Mark Tenholder, MD; March 2004Revised:
Steven Frick, MD; August 2006Harish Hosalkar, MD; April 2011
Joshua Klatt, MD; November 2011
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“Hip fractures in children are of interest because of the frequency of complications rather than the frequency of fractures.”
Canale
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Femoral Neck Fractures in Children
Rare fracture Anatomic and vascular differences Emergent treatment High complication rate
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Background
Different from Adults– High-energy– Thick periosteum– Vascularity– Physes– Treatment options
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Background
Osseous Anatomy– Proximal femoral
physis– Trochanteric
apophysis– Dense bone– Small neck
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Background
Vascular Anatomy– Immature– Variable
Ligamentum teres Lateral epiphyseal
vessels (bypass physis) Metaphyseal
circulation (after physeal closure)
– Vulnerable to injury
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Mechanism
MVC Auto-ped High falls Minor trauma can still be a cause
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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.
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Type ITransepiphyseal
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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.
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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.
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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.
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Type IExample
10 yr female Type I fracture-
dislocation of hip
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Type IExample
ORIF and Pins Attempted
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Type IExample
Postop film Malreduced and
dislocated
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Type IExample
Repeat ORIF
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Type IExample
3 month follow-up
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Type IExample
8 Months Heterotopic ossification evident
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Type IExample
11 Months Osteonecrosis
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Type IITranscervical
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Type II
Most common type (50% of peds hip fx)
Most common AVN (50%)
3/4 will be displaced
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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.
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Type IITreatment
Nondisplaced– Spica cast, if young– Use internal fixation,
if older– If in doubt, treat as
displaced
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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
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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.
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Type IIICervicotrochanteric
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Type III
Second most common– 35% of peds hip fx
Second highest AVN rate– 25-30%
2/3 displaced
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.
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Type IIITreatment
Nondisplaced – Spica cast – Follow closely for
loss of reduction Displaced
ORIF– Cannulated screws– Peds hip screw
Avoid physes
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.
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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.
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Type IIIExample
6 year old femal MVC Liver laceration Ipsilateral femoral
neck, femur, and tibia fractures
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Type IIIExample
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Type IIIExample
8 wks post-op Union Cast removed,
WBAT No AVN
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Type IVIntertrochanteric
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Type IV
Not common – 10-15% of peds hip fx
Fewest complications AVN still possible,
but unusual
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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
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Type IVResults
Generally good Fewest complications
– High energy still can result in AVN (10-20%)
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Type IVExample
14 year old male Motorcycle crash
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Type IVExample
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Type IVExample
9 weeks post-op
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Type IVExample
9 months post-op
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Type IVExample
10 months post-op After hardware removal
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Type IVExample
15 months post-op AVN
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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
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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
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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.
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Hip FractureAVN
Most common and devastatingcomplication
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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.
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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
Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:87–96.
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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
Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:87–96.
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AVNClassification
Ratliff 1962Ratliff A. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962 Aug.;44-B:528–542.
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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.
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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.
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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.
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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.
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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.
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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
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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.
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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
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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.
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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
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Hip DislocationsTreatment
Operative indications– Delayed treatment– Irreducible dislocation– Incongruous or
incomplete reduction with interposed bone or soft tissue
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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
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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
Herrera-Soto. Traumatic hip dislocations in children and adolescents: pitfalls and complications. J Am Acad Orthop Surg. 2009;17:15.
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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
Herrera-Soto. Traumatic hip dislocations in children and adolescents: pitfalls and complications. J Am Acad Orthop Surg. 2009;17:15.
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Hip DislocationsExample 1
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Hip DislocationsExample 1
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Hip DislocationsExample 1
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Hip DislocationsExample 1
After anterolateral open reduction
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Hip DislocationsExample 2
12 yr male with reduced hip dislocation and increased medial joint space
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Hip DislocationsExample 2
Inadequate reduction due to interposition
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Hip DislocationsExample 2
Open surgical dislocation: Trochanteric flip approach
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Hip DislocationsExample 2
Intra-articular loose tissue (post-labral piece)
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Hip DislocationsExample 2
6 month follow-up
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Hip DislocationsExample 2
15 month follow-up. No evidence of AVN.
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Bibliography Bagatur AE, Zorer G. Complications associated with surgically treated hip fractures in children. J
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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.
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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.
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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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