Proximal femur fracture - pediatrics.pptx

Here's ppt on pediatric femoral neck fractures. Suggestions welcomed on [email protected].

1. Proximal femur fracture - pediatrics

2. introduction Proximal Femur Fractures in the pediatric population are rare fractures caused by high-energy trauma and are often associated with polytrauma. Incidence accounts for < 1% of pediatric fractures Demographics males more commonly affected 2.5:1 Bimodal distribution children < 2-3 years old due to non-accidental trauma adolescents involved in motor vehicle accidents

3. anatomy OSTEOLOGY proximal femur develops from 2 centers of ossification 1- Proximal femoral epiphysis ossification begins at 4-6 months in girls and 5-7 months in boys responsible for metaphyseal growth of femoral neck rate of growth is 3 mm/year accounts for 13-15% of overall leg length accounts for 30% of overall femur length 2- Trochanteric apophysis ossification begins at 4 years in both girls and boys responsible for appositional growth of greater trochanter & also makes small contribution to growth of femoral neck and intertrochanteric femur 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

4. BLOOD SUPPLY

5. 1 . Medial femoral circumflex artery (MFCA)    via the posterosuperior and posteroinferior retinacular branches  at birth, contributes to the blood supply to the head with the LFCA and artery of ligamentum teres at 4 years old, becomes the main blood supply after regression of the LFCA and artery of ligamentum teres   2 . Lateral femoral circumflex artery (LFCA) at birth, contributes to the blood supply to the head regresses in late childhood 3 . Artery of the ligamentum teres at birth, contributes to the blood supply to the head diminishes after 4 years old 4. Metaphyseal vessels also contribute to blood supply to the head < 3 years old and after 14-17 years between 3 to 14-17 years, the physis blocks metaphyseal supply after 14-17 years, anastomoses between metaphyseal -epiphyseal vessels develop BLOOD SUPPLY

6. Presentation Symptoms severe pain in affected hip inability to bear weight Physical exam shortened, externally rotated lower extremity Classification DELBET

7. Imaging Radiographs Recommended views AP cross-table lateral bone survey if suspected non-accidental trauma Findings break/offset of bony trabeculae near Ward triangle  CT Indications nondisplaced fractures and stress fractures MRI Indications nondisplaced fractures and stress fractures (preferred over CT) pathologic fractures Findings well-defined low-signal line and surrounding high-signal bone edema on T2-weighted images

8. Differential Legg-Calve- Perthes disease Slipped Capital Femoral Epiphysis (SCFE) Toxic synovitis Spontaneous hemarthrosis Infection Treatment Depends on 3 factors Age <2yrs 2-10yrs >10yrs Delbet type 1-4 Displacement +/-

9. General principles Anatomic reduction should be achieved as soon as possible (ideally within 24hrs) early reduction (< 24h) may diminish risk of AVN by restoring blood flow through kinked vessels Holding the reduction EXT FIXATION (CAST) only <2yrs /<2yrs + undisplaced + any delbet type INT & EXT FIXATION 2-10yrs / any displaced # / Delbet type 2 or 3 INT FIXATION only >10yrs with stable fixation IMPLANT options = smooth pins / threaded pins / cannulated screws / DHS

10. Different techniques Closed reduction and spica abduction casting Technique fracture table (preferred for most patients) can use radiolucent table for younger patients apply gentle longitudinal traction(hip flx ~ 45 knee flx ~70) with abduction(~30) and internal rotation(~5) follow with weekly radiographs for 3 weeks to make sure reduction maintained Acceptable alignment type II accept < 2mm cortical translation, < 5° of angulation, no malrotation type III and IV accept < 10° of angulation

11. Closed reduction and percutaneous pinning (CRPP) Instrumentation smooth or threaded pins/K wires indications type I without epiphyseal dislocation, II, III in patients < 4yrs cannulated screws indications type I without epiphyseal dislocation, II, III in patients > 4yrs Technique Pin/screw placement short of the physis (indications) patients < 4-6yrs / most type III fractures less stable than transphyseal transphyseal  (indications) older patients close to skeletal maturity (> 12yrs old) when there is little metaphyseal bone available where crossing the physis is necessary to achieve stable fixation as it is easier to treat leg length discrepancy from premature physeal closure than nonunion place within 5mm of subchondral bone avoid anterolateral quadrant of epiphysis and posterior perforation of femoral neck to prevent injury to vasculature

12. 3. ORIF with pin/screw fixation Indications type I II, III if unable to achieve closed anatomic reduction Severely displaced fractures Pathologic fractures Approach Anterior(smith-Peterson) Anterolat(Watson-jones) Lateral( hardinge ) 4. ORIF with sliding hip screw (DHS) Indications type IV if displaced or > 4 years old

13. Emergent ORIF with capsulotomy (or joint aspiration) Indications open hip fractures (rare) vessel injury where large vessel repair is required (rare) concomitant hip or epiphyseal dislocations (especially type I) fractures with significant displacement some data suggests this may decrease the rate of AVN Technique aspiration with large bore needle through subadductor /anterior hip approach open capsulotomy through anterior incision

14. Post operative management Additional spica cast immobilization after surgical stabilization Depends on the fracture type , patient age and quality of the fixation Compliance with postoperative weight bearing and activity Restrictions Non weight bearing for 6 weeks – flby progressive weight bearing till union

15. Conclusion Multiple studies supports importance of early surgical fixation of proximal femoral fractures in pediatric patients An operative intervention later than 48hr after Initial trauma may increase the risk of complications such as FH necrosis , especially in delbet type 1 fractures (acute SCFE) Post operative protocol eg , the time interval of limited weight bearing or an additional cast fixation DOES NOT contribute significantly to the functional or radiological outcome

16. Complications AVN Most common complication Risk factors Modifieble Early # reduction / anatomic reduction / capsular decompression Non modifiable Initial # displacement / older age at time of presentation / type of # ( delbet )- nearly 100% with type 1 Etiology kinking/laceration of vessels tamponade by intracapsular hematoma Classification - Ratliff type I - involvement of whole head type II - partial involvement of head type III - area of necrosis in femoral neck from fracture line to physis

17. Treatment summary for peds AVN Surgical procedure Indication 1 Prox imal femur osteotomy Partial AVN with viable surface 2 Core decompression Precollapse (stage 1&2) AVN 3 Free vascular fibular autograft Postcollapse (stage 3&4) AVN 4 Bisphophonate therapy Precollapse AVN 5 Hip Arthrodesis Salvage option 6 THA Salvage option

18. 2. Coxa vara (neck-shaft angle <120°) 2nd most common complication Risk factors more common if fracture is treated non-operatively more common for type I, II and III fractures Treatment young patients (0-3 yrs ) will remodel if neck-shaft angle > 110° S urgical arrest of trochanteric apophysis Indications mild coxa vara in < 6-8 yrs only works in younger patients 2. S ubtrochanteric or intertrochanteric valgus osteotomy indications coxa vara with nonunion coxa vara with severe Trendelenburg limp or signs/symptoms of FAI older patients

19. 3. Coxa valga seen in type IV fractures involving GT in younger patients due to premature GT apophysis closure 4. Nonunion   can occur together with coxa vara etiology nonoperative treatment of type II or III fractures occult infection at fracture site malreduced fracture treatment ORIF and immobilization ( spica cast if younger patient) subtrochanteric or intertrochanteric valgus osteotomy bone grafting if persistent

20. 5. Physeal arrest can lead to leg length discrepancy proximal femoral physis contributes to 15% of overall limb length (3 mm/ yr ) Risk factors penetration of physis by fixation devices AVN 6 . Limb length discrepancy (LLD) significant LLD occurs in combined AVN and physeal arrest Treatment shoe lift if projected LLD at skeletal maturity is < 2cm epiphysiodesis of contralateral distal femur ± proximal tibia if projected LLD at skeletal maturity is 2-5cm

21. 7. Chondrolysis usually associated with AVN etiology poor vascularity to femoral head cartilage penetration of hardware into joint presents as restricted hip motion, hip pain, radiographic joint space narrowing 8. Malreduction common with subtrochanteric fractures deforming forces lead to proximal fragment in flexion, abduction, and external rotation 9 . Infection

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