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Fractures and Dislocations about the

Hip in the Pediatric Patient

Not Adults

• High-energy
• Thick periosteum
• Vascularity
• Physes
• Treatment options

Osseous Anatomy

• Proximal femoral physis
• Trochanteric apophysis
• Dense bone
• Small neck

Vascular Anatomy

• Immature
• Variable
  • Ligamentum teres
  • Metaphyseal circulation
  • Lateral epiphyseal vessels (bypass physis)
• Vulnerable to injury

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.

Type I

• Very rare
• Little evidence
• Can we improve results?

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

Type I

• RESULTS

• Generally poor
• Catastrophic with concurrent dislocation

Type II

• Most common type (50% of peds hip fx)
• Most common AVN (50%)
• 3/4 will be displaced

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

Type II

• Treatment
  • May require open reduction
  • Adequate reduction

Type II

• Results
• Nondisplaced  Less complications
• Outcome in literature is variable
• Highest complication rate of the 4 types
• Improved with IF

Type III

• Second most common (35% of peds hip fx)
• Second highest AVN rate (25-30%)
• 2/3 will be displaced

S.E.-Follow Up

• 8 wks post-op:
• Union
• No AVN
• Cast removed, WBAT

Type III

• Treatment
  • Nondisplaced:
    • cast
    • follow closely for loss of reduction
  • Displaced:
    • IF
    • cannulated screws or peds hip screw
    • avoid physes

Type III

• Results
• Similar to type II
• Nondisplaced  Less complications
• Outcome in literature is variable
• IF reduces coxa vara and nonunion

Type IV

• Not common (10-15% of peds hip fx)
• Fewest complications
• AVN still possible, but unusual

Type IV

• Treatment
• Most agreement between authors
• Conservative in younger children

Type IV

• Treatment
• Spica in younger patients
• Pediatric hip screw in older pts, or those with unstable reduction

Type IV

• Results
• Generally good
• Fewest complications- high energy still can result in AVN

TX Highlights

• of nondisplaced fractures is small, so

  conclusions are difficult
• Most nondisplaced fractures can be treated in a cast
• Exceptions: older child, type II

TX Highlights

• Surgery and implants available now are different than those used in older literature
• More recent emphasis on internal fixation
• Implant depends on age
  • <3 smooth pins
  • 3-8 4.0 screws, peds hip screw
  • 8+ 6.5 screws, peds or adult hip screw, blade plate
• Expanded indications in polytrauma pt’s

AVN

• 40-45% overall rate
• Type I ?, ~100% with dislocation
• Type II 50%
• Type III 25%
• Type IV 10%

AVN

• Displacement vs. Hematoma

AVN-Hematoma

• Animal studies
• Boitzy: No AVN, 11 type II, early evacuation
• Swiontkowski and Winquist: 6 displaced II’s and III’s, CR, capsulotomy, IF. No AVN.
• Pforringer: 6% AVN in displaced type I-III that were decompressed within 36 hrs