1. 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

2. “Hip fractures in children are of interest because of the frequency of complications rather than the frequency of fractures.”
Canale

3. Femoral Neck Fractures in Children
Rare fracture
Anatomic and vascular differences
Emergent treatment
High complication rate

4. Background Different from Adults High-energy Thick periosteum
Vascularity
Physes
Treatment options

5. Background Osseous Anatomy Proximal femoral physis
Trochanteric apophysis
Dense bone
Small neck

6. Background Vascular Anatomy Immature Variable Vulnerable to injury
Ligamentum teres
Lateral epiphyseal vessels (bypass physis)
Metaphyseal circulation (after physeal closure)
Vulnerable to injury

7. Mechanism
MVC
Auto-ped
High falls
Minor trauma can still be a cause

8. 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.

9. Type I Transepiphyseal

10. 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 Jun.;59(4):431–443.

11. Type I Treatment Nondisplaced Displaced Can treat with spica cast 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 Feb.;12(2):164–168.

12. Type I Results
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 Apr.;92(4):973–977.

13. Type I Example
10 yr female
Type I fracture-dislocation of hip

14. Type I Example
ORIF and Pins Attempted

15. Type I Example
Postop film
Malreduced and dislocated

16. Type I Example
Repeat ORIF

17. Type I Example
3 month follow-up

18. Type I Example
8 Months
Heterotopic ossification evident

19. Type I Example
11 Months
Osteonecrosis

20. Type II Transcervical

21. Type II Most common type (50% of peds hip fx) Most common AVN (50%)
3/4 will be displaced

22. Type II Historical treatment
Nondisplaced
Displaced
Lam (1971)
Traction/Cast
Traction/CR Cast
Ratliff (1962)
Cast IF
Canale (1977)
Quick (2005)
CR vs OR with IF
Historical treatment
Internal fixation is currently the treatment of choice
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.
Quick. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;(432):87–96.

23. Type II Treatment Nondisplaced Spica cast, if young
Use internal fixation, if older
If in doubt, treat as displaced

24. Type II Treatment 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

25. Type II Results Nondisplaced Outcome in literature is variable
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 May 26;3(4):259–264.

26. Type III Cervicotrochanteric

27. Type III Second most common Second highest AVN rate 2/3 displaced
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 May 26;3(4):259–264.

28. Type III Treatment Nondisplaced Displaced 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 May 26;3(4):259–264.

29. Type III Results 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.

30. Type III Example 6 year old femal MVC Liver laceration
Ipsilateral femoral neck, femur, and tibia fractures

31. Type III Example

32. Type III Example
8 wks post-op
Union
Cast removed, WBAT
No AVN

33. Type IV Intertrochanteric

34. Type IV Not common Fewest complications
10-15% of peds hip fx
Fewest complications
AVN still possible, but unusual

35. Type IV Treatment Most agreement between authors Nondisplaced
Hip-spica in younger patients
Displaced
Pediatric hip screw in older pts
Or in those with unstable reduction

36. Type IV Results Generally good Fewest complications
High energy still can result in AVN (10-20%)

37. Type IV Example
14 year old male
Motorcycle crash

38. Type IV Example

39. Type IV Example
9 weeks post-op

40. Type IV Example
9 months post-op

41. Type IV Example
10 months post-op
After hardware removal

42. Type IV Example
15 months post-op
AVN

43. Hip Fracture Treatment Highlights
Data on nondisplaced fractures is limited
Conclusions are difficult
Most nondisplaced fractures can be treated in a cast
Exceptions
Older child
Type II

44. Hip Fracture Treatment 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

45. Hip Fracture Complications
AVN
Coxa Vara
Physeal Closure
Nonunion
Delayed Union
Ratliff
42%
20%
15%
10%
24%
Lam
17%
30%
Canale
43%
21%
62% 7%
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.

46. Hip Fracture AVN
Most common and devastating
complication

47. Hip Fracture AVN 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.

48. Hip Fracture AVN 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.

49. Hip Fracture AVN 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.

50. AVN Classification Ratliff 1962
Ratliff A. Fractures of the neck of the femur in children. J Bone Joint Surg Br Aug.;44-B:528–542.

51. AVN Risk Factors Degree of Initial Displacement Timing of reduction
Nondisplaced
None in most series
Displaced
43% to 88% rate
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.

52. AVN Risk Factors Quality of reduction Capsular decompression
Excellent/anatomic reduction
0% to 17% AVN
Nonanatomic/fair/poor
70% to 100% AVN
No decompression
50%
Decompression
0% to 10%
-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.
-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.

53. 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 Aug.;81(4):442–445.

54. 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.

55. 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.

56. 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

57. 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.

58. 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

59. 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.

60. 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

61. Hip Dislocations Treatment
Operative indications
Delayed treatment
Irreducible dislocation
Incongruous or incomplete reduction with interposed bone or soft tissue

62. Hip Dislocations Treatment
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

63. Hip Dislocations 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.

64. Hip Dislocations Summary
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.

65. Hip Dislocations Example 1

66. Hip Dislocations Example 1

67. Hip Dislocations Example 1

68. Hip Dislocations Example 1
After anterolateral open reduction

69. Hip Dislocations Example 2
12 yr male with reduced hip dislocation and increased medial joint space

70. Hip Dislocations Example 2
Inadequate reduction due to interposition

71. Hip Dislocations Example 2
Open surgical dislocation: Trochanteric flip approach

72. Hip Dislocations Example 2
Intra-articular loose tissue (post-labral piece)

73. Hip Dislocations Example 2
6 month follow-up

74. Hip Dislocations Example 2
15 month follow-up. No evidence of AVN.

75. Bibliography
Bagatur AE, Zorer G. Complications associated with surgically treated hip fractures in children. J Pediatr Orthop B Jul.;11(3):219–228.
Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg Am 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 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 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 Jan.;84(1):108–112.
Forlin E, Guille JT, Kumar SJ, Rhee KJ. Transepiphyseal fractures of the neck of the femur in very young children. J Pediatr Orthop Feb.;12(2):164–168.
Herrera-Soto JA, Price CT. Traumatic hip dislocations in children and adolescents: pitfalls and complications. J Am Acad Orthop Surg Jan.;17(1):15–21.
İnan U, Köse N, Ömeroğlu H. Pediatric femur neck fractures: a retrospective analysis of 39 hips. J Child Orthop May 26;3(4):259–264.
Lam SF. Fractures of the neck of the femur in children. J Bone Joint Surg Am Sep.;53(6):1165–1179.

76. Bibliography
Mirdad T. Fractures of the neck of femur in children: an experience at the Aseer Central Hospital, Abha, Saudi Arabia. Injury 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 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 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 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 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 Jan.;454:169–173.

77. Thank You
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