Fractures and Dislocations about the Hip in the Pediatric Patient

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. Type II • 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. Type III • 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

38. 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. Type IV • 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