fractures and dislocations about the hip in the pediatric patient

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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

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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. - PowerPoint PPT Presentation

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  • Fractures and Dislocations about the Hip in the Pediatric PatientJoshua Klatt, MD

    Original Author: Mark Tenholder, MD; March 2004Revised: Steven Frick, MD; August 2006Harish Hosalkar, MD; April 2011Joshua Klatt, MD; November 2011

  • Hip fractures in children are of interest because of the frequency of complications rather than the frequency of fractures.Canale

  • Femoral Neck Fractures in ChildrenRare fractureAnatomic and vascular differencesEmergent treatmentHigh complication rate

  • BackgroundDifferent from AdultsHigh-energyThick periosteumVascularityPhysesTreatment options

  • BackgroundOsseous AnatomyProximal femoral physisTrochanteric apophysisDense boneSmall neck

  • BackgroundVascular AnatomyImmatureVariableLigamentum teresLateral epiphyseal vessels (bypass physis)Metaphyseal circulation (after physeal closure)Vulnerable to injury

  • MechanismMVCAuto-ped High fallsMinor trauma can still be a cause

  • ClassificationType 1 TransepiphysealType 2 TranscervicalType 3 CervicotrochantericType 4 - IntertrochantericColonna PC. Fractures of the neck of the femur in children. Am J Surg 1929;6:793-7.

  • Type ITransepiphyseal

  • Type IVery rareLittle 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. 1977 Jun.;59(4):431443.

  • Type ITreatmentNondisplacedCan treat with spica castDisplaced PastClosed reduction and spicaORIF PresentClosed or open reduction plus internal fixationThreaded pinsCannulated screwsSmooth pinsForlin E, Guille JT, Kumar SJ, Rhee KJ. Transepiphyseal fractures of the neck of the femur in very young children. J Pediatr Orthop. 1992 Feb.;12(2):164168.

  • Type IResultsRecent literature following better understanding of hip vascularityIn some circumstances the femoral head may not be completely avascular, and, with appropriate surgical care, the hip can be preservedSchoenecker 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. 2010 Apr.;92(4):973977.

  • Type IExample10 yr femaleType I fracture-dislocation of hip

  • Type IExampleORIF and Pins Attempted

  • Type IExamplePostop filmMalreduced and dislocated

  • Type IExampleRepeat ORIF

  • Type IExample3 month follow-up

  • Type IExample8 MonthsHeterotopic ossification evident

  • Type IExample11 MonthsOsteonecrosis

  • Type IITranscervical

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

  • Type IIHistorical treatmentInternal fixation is currently the treatment of choice

    Lam. Fractures of the neck of the femur in children. J Bone Joint Surg Am. 1971;53:11651179. Ratliff. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962;44-B:528542.Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg Am. 1977;59:431443.Quick. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;(432):8796.

  • Type IITreatmentNondisplacedSpica cast, if youngUse internal fixation, if olderIf in doubt, treat as displaced

  • Type IITreatmentDisplacedAnatomic reduction is important, open if necessaryDo not accept varus mal-reductionsAvoid excess traction Fracture table may be used without extreme positioning for prolonged periodCannulated screws/ threaded pins to compressAvoid physisBut stability and reduction is first priority

  • Type IIResultsNondisplacedFewer complicationsOutcome in literature is variableAVN in up to 50%Highest complication rate of the 4 typesImproved with internal fixation

    nan U, Kse N, merolu H. Pediatric femur neck fractures: a retrospective analysis of 39 hips. J Child Orthop. 2009 May 26;3(4):259264.

  • Type IIICervicotrochanteric

  • Type IIISecond most common35% of peds hip fxSecond highest AVN rate25-30%2/3 displacednan U, Kse N, merolu H. Pediatric femur neck fractures: a retrospective analysis of 39 hips. J Child Orthop. 2009 May 26;3(4):259264.

  • Type IIITreatmentNondisplaced Spica cast Follow closely for loss of reductionDisplacedORIFCannulated screwsPeds hip screwAvoid physes

    nan U, Kse N, merolu H. Pediatric femur neck fractures: a retrospective analysis of 39 hips. J Child Orthop. 2009 May 26;3(4):259264.

  • Type IIIResultsSlightly better than IINondisplacedFewer complicationsOutcome in literature is variableAVN 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;84:108112.

  • Type IIIExample6 year old femalMVCLiver lacerationIpsilateral femoral neck, femur, and tibia fractures

  • Type IIIExample

  • Type IIIExample8 wks post-opUnionCast removed, WBATNo AVN

  • Type IVIntertrochanteric

  • Type IVNot common 10-15% of peds hip fxFewest complicationsAVN still possible, but unusual

  • Type IVTreatmentMost agreement between authorsNondisplacedHip-spica in younger patientsDisplacedPediatric hip screw in older ptsOr in those with unstable reduction

  • Type IVResultsGenerally goodFewest complicationsHigh energy still can result in AVN (10-20%)

  • Type IVExample14 year old maleMotorcycle crash

  • Type IVExample

  • Type IVExample9 weeks post-op

  • Type IVExample9 months post-op

  • Type IVExample10 months post-opAfter hardware removal

  • Type IVExample15 months post-opAVN

  • Hip FractureTreatment HighlightsData on nondisplaced fractures is limitedConclusions are difficultMost nondisplaced fractures can be treated in a castExceptionsOlder childType II

  • Hip FractureTreatment HighlightsSurgery and implants available now are different than those used in older literatureMore recent emphasis on internal fixationAnatomic reduction and compression is key for successful unionSurgical approach should not further destabilize blood supply to femoral headExpanded indications in polytrauma pts

  • Hip FractureComplicationsLam. Fractures of the neck of the femur in children. J Bone Joint Surg Am. 1971;53:11651179. Ratliff. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962;44-B:528542.Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg Am. 1977;59:431443.

  • Hip FractureAVNMost common and devastatingcomplication

  • Hip FractureAVN6 53% overall rate

    Type I 57% to 100%Type II50%Type III25%Type IV10%Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:8796.

  • Hip FractureAVNAVN may develop ifThe vessels are torn in the initial injuryThe vessels are kinked at due to displacementThere is intracapsular tamponade causing vascular disruptionThe vessels are not protected during healingQuick TJ, Eastwood DM. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:8796.

  • Hip FractureAVNFactors influencing rate of AVNDegree of initial displacementTiming of reduction and fixationQuality of reductionStability of reduction and fixationDecompression of capsular hematomaWeight-bearing statusQuick TJ, Eastwood DM. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:8796.

  • AVNClassificationRatliff 1962Ratliff A. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962 Aug.;44-B:528542.

  • AVNRisk FactorsDegree of Initial DisplacementNondisplacedNone in most seriesDisplaced43% to 88% rate

    Timing of reductionLess than 24 hours0% to 6%Greater than 48 hours40% -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.

  • AVNRisk FactorsQuality of reductionExcellent/anatomic reduction0% to 17% AVNNonanatomic/fair/poor70% to 100% AVNCapsular decompressionNo decompression50%Decompression0% to 10%-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.-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.

  • Coxa Vara20-50% incidenceLoss of reduction, closure of proximal femoral physisIncidence and amount of deformity decreased by internal fixationGait abnormalities, degenerationTx: Subtrochanteric osteotomyEberl. Post-traumatic coxa vara in children following screw fixation of the femoral neck. Acta Orthop. 2010 Aug.;81(4):442445.

  • Nonunion5-10% incidenceLess with internal fixationTreatmentValgus osteotomyBone 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.

  • Physeal ClosureVariable incidence (up to 40%)Causes: AVN, implants, stimulationLeg length discrepancy often not significant, worse with AVNTx: 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.

  • SummaryDetermine Delbet type and displacementUrgent treatment with reduction and fixation as neededTreatment and implant will also be dependent on ageJoint decompression has theoretical advantages, and some literature support but quality of evidence poor

  • SummaryNondisplaced fractures will have fewer complications and will do better regardless of treatment.The more proximal the fx, the more likely to get AVNComplication rate is high. Counsel the family.

  • SummaryInternal fixation is indicated in:Displaced type IAll type IITypes III and IV if displaced or child is olderPolytraumaInternal fixation may reduce complications

  • Hip DislocationsUncommon, but more common than femoral neck fractures in childrenUsually posterior, rarely anteriorLess commonly associated with fractures than adultsResults 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.

  • Hip DislocationsUrgent reduction, closedAdequate anesthesia, relaxationCareful assessment of congruity of reductionIf uncertain consider CT/MRI to rule out intra-articular fragmentsProtected weight-bearing following reduction until full, painless ROM

  • Hip DislocationsTreatmentOperative indicationsDelayed treatmentIrreducible dislocationIncongruous or incomplete reduction with interposed bone or soft tissue

  • Open ReductionApproachesAnterior (Smith-Peterson)Anterolateral (Watson-Jones)Trans-trochantericAvoid posterior to prevent damage to the blood-vessels and potentially-preserved vascularity of the femoral head

    Trochanteric flip approachHip DislocationsTreatment

  • Hip DislocationsComplicationsComplicationsAvascular necrosis (8-20%)Myositis ossificans (8-15%)Sciatic nerve palsyEarly secondary arthritisFactors predisposing to poor result:Older childSevere traumaDelay in reduction (> 8 hours)Incongruous reductionAVNHerrera-Soto. Traumatic hip dislocations in children and adolescents: pitfalls and complications. J Am Acad Orthop Surg. 2009;17:15.

  • Hip DislocationsSummaryEarly diagnosis and prompt reductionImportant to recognize associated fracture/ inadequate reductionAdvanced imaging may be necessarySurgical approach should not further compromise blood supplyAVN is still a significant risk with 8-20% incidence in skeletally immatureDelay in reduction, high energy mechanism, and older age are risk factorsHerrera-Soto. Traumatic hip dislocations in children and adolescents: pitfalls and complications. J Am Acad Orthop Surg. 2009;17:15.

  • Hip DislocationsExample 1

  • Hip DislocationsExample 1

  • Hip DislocationsExample 1

  • Hip DislocationsExample 1After anterolateral open reduction

  • Hip DislocationsExample 212 yr male with reduced hip dislocation and increased medial joint space

  • Hip DislocationsExample 2Inadequate reduction due to interposition

  • Hip DislocationsExample 2Open surgical dislocation: Trochanteric flip approach

  • Hip DislocationsExample 2Intra-articular loose tissue (post-labral piece)

  • Hip DislocationsExample 26 month follow-up

  • Hip DislocationsExample 215 month follow-up. No evidence of AVN.

  • BibliographyBagatur AE, Zorer G. Complications associated with surgically treated hip fractures in children. J Pediatr Orthop B. 2002 Jul.;11(3):219228.Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg Am. 1977 Jun.;59(4):431443.Cheng JC, Tang N. Decompression and stable internal fixation of femoral neck fractures in children can affect the outcome. J Pediatr Orthop. 1999 Apr.;19(3):338343.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. 2010 Aug.;81(4):442445.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. 2002 Jan.;84(1):108112.Forlin E, Guille JT, Kumar SJ, Rhee KJ. Transepiphyseal fractures of the neck of the femur in very young children. J Pediatr Orthop. 1992 Feb.;12(2):164168.Herrera-Soto JA, Price CT. Traumatic hip dislocations in children and adolescents: pitfalls and complications. J Am Acad Orthop Surg. 2009 Jan.;17(1):1521.nan U, Kse N, merolu H. Pediatric femur neck fractures: a retrospective analysis of 39 hips. J Child Orthop. 2009 May 26;3(4):259264.Lam SF. Fractures of the neck of the femur in children. J Bone Joint Surg Am. 1971 Sep.;53(6):11651179.

  • BibliographyMirdad T. Fractures of the neck of femur in children: an experience at the Aseer Central Hospital, Abha, Saudi Arabia. Injury. 2002 Nov.;33(9):823827.Morsy HA. Complications of fracture of the neck of the femur in children. A long-term follow-up study. Injury. 2001 Jan.;32(1):4551.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. 1996 Jul.;27(6):419421.Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;(432):8796.Ratliff A. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962 Aug.;44-B:528542.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. 2010 Apr.;92(4):973977.Shrader MW, Jacofsky DJ, Stans AA, Shaughnessy WJ, Haidukewych GJ. Femoral Neck Fractures in Pediatric Patients. Clin Orthop Relat Res. 2007 Jan.;454:169173.

  • Thank YouReturn to Pediatrics IndexIf you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to [email protected]