2. < 1% of all pediatric #
<1 % of prevalence of hip # in adults.
Exceedingly rare.
3. Difference from adult
Anatomy
Proximal femoral epiphysis is at a risk of fracture
Orientation of trabeculae in femoral neck in children is not
along the stress lines
Smooth Fracture surfaces, with very little interlocking
impaction closed reduction less stable.
4. Blood vessels to the femoral head are easily damaged, and a
high incidence of AVN occurs in fractures in children than
adults.
Growth arrest in the physis can cause shortening of up to
15% of the total extremity
Varus or valgus angulation of the femoral neck also can
occur from arrest of only one side of the physis.
5. A child can tolerate immobilization much more readily than
an adult, and thus more choices for treatment are available,
including traction, a spica cast, and bed rest, in addition to
operative treatment.
Fixation devices causes growth arrest.
6. MECHANISM OF INJURY
Axial loading, torsion, hyperabduction or a direct blow
injury.
Severe high energy trauma.
Proximal femur in children is extremely strong
Fracture after minor injury suggests weaker bone.
Bone cysts, infection.
7. Applied Anatomy
During early childhood only a single proximal femoral physis
exists.
During I yr of life medial portion grows faster creating long
neck.
PFE begins to ossify at 4 – 6 months.
Trochanteric apophysis – 4 yrs.
PFP metaphyseal growth of the neck
Fusion of physis 14 – 16 yrs.
9. Ligamentum teres little B.S
At birth Metaphyseal vessels predominate.
Gradually diminish as physis develops.
[barrier], non existent by 4 yrs.
Lateral epiphyseal vessels – posterosuperior &
posteroinferior branches of MCFA
At intertrochanteric groove, MCFA branches in to the
retinacular arterial system.
10. Capsulotomy does not damage B.S but violation of IT notch
or LACV avascular.
At 3-4 yrs, lateral posterosuperior vessels appear to
predominate.
PI & PS vessels persists through out life.
Multiple small vessels coalesce with age.
11. Confluence of GT physis with capital femoral epiphysis along
the superior femoral neck & unique vascular supply to CFE
makes immature hip vulnerable to growth derangement &
subsequent deformity after a fracture.
12. DELBET CLASSIFICATION
TYPE I : Transepiphyseal separation
I A : With dislocation
II B: With out dislocation.
TYPE II : Transcervical fracture
TYPE III : Cervicotrochanteric fracture.
TYPE IV : Intertrochanteric fracture.
15. High energy trauma
8 % of NOF
In a new born during a difficult breach delivery [proximal
femoral epiphysiolysis] mistaken with DDH.
During CR of traumatic dislocations hip.
50% @ with dislocation of CFE.(100% complication)
< 2 yrs of age better prognosis.
AVN unlikely but other comp, can occur.
18. 46% of # NOF
Most common type
Difficult to treat in spica.
70% displaced at presentation
Incidence of AVN related to initial displacement.
AVN 50% [ common comp].
24. Type 1 # in neonate
Exceedingly rare
A strong suspicion, [F.H not visible] pseudoparalysis &
shortening – key for diagnosis.
holds the limb in flexed, abducted & ext. rotated.
DD – septic arthritis & hip dislocation.
High riding PF metaphysis.
USG.
25. Clinical features
Pain in the hip
Shortened & externally rotated limb.
Non displaced # walk with limp.
INVESTIGATIONS:
X ray pelvis AP & Cross table lateral view.
Any Break or offset of bony trabeculae near Ward’s triangle
impacted #.
26. Radioisotopic bone scan 48 hrs after onset, increased
uptake in # site.
MRI detects # with in first 24 hrs.
27. TREATMENT type -I
Based on age & fracture stability after reduction.
< 2 yrs with minimally displaced #, CR & spica cast
application.
# tends to displace in to varus & ext.rotation, limb should be
in mild abduction & neutral rot.
Displaced # reduced by gentle traction, abduction & IR.
28. < 6-8 Yrs smooth pins
> 8 Yrs cannulated cancellous screws
Older children should undergo fixation even undisplaced.
Postop spica must in all except for adolescents.
Implants removed shortly # healing [8-12 wks]
29. TYPE 1 B
One attempt CR, if not immediate OR from the side of
dislocation.
Generally posterolateral approach.
30. TYPE II & III
Anatomic reduction & stable IF always indicated to minimize risk
of complications.
Non displaced type 2 # in children < 5 yrs spica, wants close
follow-up.
Open reduction Watson & Jones approach
Screws to be inserted short of physis.
If not good purchase penetrate the physis.
Treatment of # is priority, growth disturbance & LLD are
secondary,
31.
32. TYPE IV
Good results with traction & spica, regardless of
displacement.
Indications for IR
- failure to maintain reduction
- polytrauma
- older children
Pediatric hip screw.
33. SURGICAL TIPS
Always predrill & tap before inserting screws.
Avoid crossing the physis but cross it if necessary for
stability.
Postop, hip spica for 6-12 wks if < 10 yrs,
34. COMPLICATIONS:-
Avascular necrosis
Most serious & most frequent
Overall prevalence 30%.
Primary cause of poor results.
Highest after type IB, II, III.
Initial # displacement, damage to blood vessels, #
hematoma.
35. RATLIFF CLASSIFICATION
TYPE I : Involvement of whole head
- most severe & most common form
- poorest prognosis
-damage to all lateral epiphyseal vessels
TYPE II: Partial involvement
- localized damage to one or more LEV.
TYPE III: an area of AVN from # to physis
- damage to superior metaphyseal V.
- rare but good prognosis.
36.
37. X ray ; as early as 6 wks, decreased density of FH with
widening of jt space.
Can develop as late as 2 yrs, so all pt to be followed for
atleast 2 yrs.
Tc bone scan
MRI; no AVN with in 6 wks ,it is unlikely to occur.
39. COXA VARA
20-30% prevalence
Lower in internal fixed pts.
causes: malunion, AVN, premature physeal closure or a
combination of above.
Raises GT in relation to FH causing shortening of extremity
& abductor lurch.
Subtrochanteric valgus osteotomy if C.vara persists > 2 yrs.
[>110*, in > 8 yrs]
40. PREMATURE PHYSEAL CLOSURE
28% of #
Risk increases with penetration of fixation devices or when
AVN
M.F after type II or III AVN.
Shortening not significant except in younger
Trochanteric epiphysiodesis – progressive coxa vara.
41. NON UNION
7% of #
Not seen after type 1 & IV
Primary cause – failure to obtain or maintain reduction.
If the child had pain & no bridging new bone at 3 months
post injury.
Subtrochanteric valgus osteotomy / rigid IR +/- bone
grafting.
43. STRESS FRACTURE
Repetitive cycle loading of hip by new or increased
activity.
Adolescent female athlete, anorexia nervosa, &
osteoporosis.
X rays only reveal after 4-6 wks
DEVAS classification
1. Compression - non wt bearing, coxa vara.
2. Tension – inherently unstable, insitu fixation
