Proximal Femur fracture in pediatrics

Dr. Muhammad BilalResident Trauma & Orthopedic department

PIMS

Growth centers of proximal femur

Blood supply of head of femur

Fracture classification

Treatment

Complications

INDEX

proximal femoral epiphysis◦ accounts for 13-15% of leg length◦ accounts for 30% length of femur◦ proximal femoral physis grows 3 mm/yr◦ entire lower limb grows 23 mm/yr

Trochanteric apophysis◦ Traction apophysis◦ contributes to femoral neck growth◦ disordered growth

injury to the GT apophysis leads to shortening of the GT and coxa valga

overgrowth of the GT apophysis leads to coxa vara 

Growth centers of proximal femur

medial femoral circumflex artery◦ main blood supply to the head via the posterosuperior lateral epiphyseal

branch and via posteroinferior retinacular branch  ◦ becomes main blood supply after 4 years after regression of LFCA and artery

of ligamentum teres lateral femoral circumflex artery

◦ regresses in late childhood  artery of the ligamentum teres

◦ diminishes after 4 years old metaphyseal vessels

◦ also contribute to blood supply to the head < 3 years old and after 14-17years between 3 to 14-17 years, the physis blocks metaphyseal supply after 14-17 years, anastomoses between metaphyseal-epiphyseal vessels develop

Blood supply

Delbet Classification   Type Description Incidence AVN Nonunion 

Type I Transphyseal (IA, without dislocation of epiphysis from

acetabulum; IB, with dislocation of epiphysis)

<10% 38%  

Type II Transcervical 40-50% 28%15%

 

Type III Cervicotrochanteric (or basicervical)

30-35% 18%15-20%

Type IV Intertrochanteric 10-20% 5% 5%

TREATMENT

TREATMENT

Avascular necrosis Coxa vara Non-union Limb length discripency Chondrolysis Infection

Complications

Avascular necrosis  most common complication

◦ most susceptible age for AVN is 3-8 years◦ risk of AVN is highest for Delbet type I and nearly

100% for Delbet type IB    etiology

◦ kinking of vessels◦ laceration of vessels◦ tamponade by intracapsular hematoma

treatment◦ core decompression◦ vascularized fibular graft

Complications

COXA VARA (neck-shaft angle <130deg) 2nd most common complication more common if fracture is treated non-

operatively more common for types I, II and III 

◦ incidence 25% for type III

Treatment young patients (0-3yrs) will remodel surgical arrest of trochanteric apophysis

◦ indication coxa vara in <6-8yrs

subtrochanteric or intertrochanteric valgus osteotomy

◦ indication coxa vara + nonunion  

NONUNION can occur together with coxa vara etiology

◦ nonoperative treatment of Type II or III◦ occult infection at fracture site◦ severe AVN of proximal femur

Treatment◦ subtrochanteric or intertrochanteric valgus

osteotomy

Limb length discrepancy significant LLD occurs in combined AVN +

physeal arrest treatment

◦ shoe lift indications

projected LLD at skeletal maturity <2cm◦ epiphysiodesis of contralateral distal femur and/or

proximal tibia indications

projected LLD at skeletal maturity 2-5cm

Chondrolysis◦ usually associated with AVN◦ etiology

poor vascularity to femoral head cartilage persistent hardware penetration of joint

◦ presents as restricted hip motion, hip pain, radiographic joint space narrowing

Infection <1% incidence after ORIF or CRPP treatment

◦ debridement, maintain fixation until union may lead to osteomyelitis, AVN,

chondrolysis, premature physeal closure

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