proximal femur fracture in children.

1. Dr. Muhammad Bilal
Resident Trauma & Orthopedic department
PIMS

2.  Growth centers of proximal femur
 Blood supply of head of femur
 Fracture classification
 Treatment
 Complications

3.  proximal femoral epiphysis
◦ accounts for 13-15% of leg length
◦ accounts for 30% length of femur
◦ proximal femoral physis grows 3 mm/yr
◦ entire lower limb grows 23 mm/yr
 Trochanteric apophysis
◦ Traction apophysis
◦ contributes to femoral neck growth
◦ disordered growth
 injury to the GT apophysis leads to shortening of the
GT and coxa valga
 overgrowth of the GT apophysis leads to coxa vara

4.  medial femoral circumflex artery
◦ main blood supply to the head via the posterosuperior lateral epiphyseal
branch and via posteroinferior retinacular branch
◦ becomes main blood supply after 4 years after regression of LFCA and
artery of ligamentum teres
 lateral femoral circumflex artery
◦ regresses in late childhood
 artery of the ligamentum teres
◦ diminishes after 4 years old
 metaphyseal vessels
◦ also contribute to blood supply to the head < 3 years old and after 14-
17years
 between 3 to 14-17 years, the physis blocks metaphyseal supply
 after 14-17 years, anastomoses between metaphyseal-epiphyseal vessels
develop

6. Delbet Classification
Type Description Incidence AVN Nonunion
Type I Transphyseal (IA, without
dislocation of epiphysis from
acetabulum; IB, with dislocation
of epiphysis)
<10% 38%
Type II Transcervical 40-50% 28%
15%
Type III Cervicotrochanteric (or
basicervical)
30-35% 18%
15-20%
Type IV Intertrochanteric 10-20% 5% 5%

11.  Avascular necrosis
 Coxa vara
 Non-union
 Limb length discripency
 Chondrolysis
 Infection

12.  Avascular necrosis
most common complication
◦ most susceptible age for AVN is 3-8 years
◦ risk of AVN is highest for Delbet type I and nearly
100% for Delbet type IB
 etiology
◦ kinking of vessels
◦ laceration of vessels
◦ tamponade by intracapsular hematoma
 treatment
◦ core decompression
◦ vascularized fibular graft

13. COXA VARA (neck-shaft angle <130deg)
 2nd most common complication
 more common if fracture is treated non-
operatively
 more common for types I, II and III
◦ incidence 25% for type III

14. Treatment
 young patients (0-3yrs) will remodel
 surgical arrest of trochanteric apophysis
◦ indication
 coxa vara in <6-8yrs
 subtrochanteric or intertrochanteric valgus
osteotomy
◦ indication
 coxa vara + nonunion

15. NONUNION
 can occur together with coxa vara
 etiology
◦ nonoperative treatment of Type II or III
◦ occult infection at fracture site
◦ severe AVN of proximal femur
 Treatment
◦ subtrochanteric or intertrochanteric valgus
osteotomy

16. Limb length discrepancy
 significant LLD occurs in combined AVN +
physeal arrest
 treatment
◦ shoe lift
 indications
 projected LLD at skeletal maturity <2cm
◦ epiphysiodesis of contralateral distal femur and/or
proximal tibia
 indications
 projected LLD at skeletal maturity 2-5cm

17. Chondrolysis
◦ usually associated with AVN
◦ etiology
 poor vascularity to femoral head cartilage
 persistent hardware penetration of joint
◦ presents as restricted hip motion, hip pain,
radiographic joint space narrowing

18. Infection
 <1% incidence
 after ORIF or CRPP
 treatment
◦ debridement, maintain fixation until union
 may lead to osteomyelitis, AVN, chondrolysis,
premature physeal closure

19. THANK YOU