Download - P08 pediatric hip
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Fractures and Dislocations about the Hip
in the Pediatric Patient
Mark Tenholder, MD
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• “Hip fractures in children are of interest because of the frequency of complications rather than the frequency of fractures.”
• Canale
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• 1. Rare fracture• 2. High complication rate• 3. Emergency?
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Displaced Femoral Neck Fracture
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Not Adults
• High-energy• Thick periosteum• Vascularity• Physes• Treatment options
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Osseous Anatomy
• Proximal femoral physis• Trochanteric apophysis• Dense bone• Small neck
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Vascular Anatomy
• Immature• Variable
– Ligamentum teres– Metaphyseal circulation– Lateral epiphyseal vessels (bypass physis)
• Vulnerable to injury
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Mechanism
• MVC, car vs. ped, high falls• Minor trauma can still be a cause
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Classification
Delbet 1928
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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.
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Type I
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Type I
• Very rare• Little evidence • Can we improve results?
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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
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Type I
• With dislocation– CT– One attempt closed– Approach dictated by dislocation
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Type I
• RESULTS• Generally poor• Catastrophic with concurrent dislocation
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Type II
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Type II
• Most common type (50% of peds hip fx)• Most common AVN (50%)• 3/4 will be displaced
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Type II
• IF is treatment of choice currently
ND/min.displaced displaced
Lam Cast Mystery
Ratliff Cast IF
Canale IF IF
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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
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Type II
• Treatment– May require open reduction– Adequate reduction
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Type II
• Results
• Nondisplaced Less complications• Outcome in literature is variable• Highest complication rate of the 4 types• Improved with IF
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Type III
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Type III
• Second most common (35% of peds hip fx)• Second highest AVN rate (25-30%)• 2/3 will be displaced
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S.E.--Injury
• 6 yo• MVC• Liver laceration• Ipsilateral femoral
neck, femur, and tibia fractures
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S.E.--Injury
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S.E.--OR (hosp. day 2)
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S.E.--OR
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S.E.--OR
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S.E.--Follow Up
•8 wks post-op:• Union• No AVN• Cast removed, WBAT
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Type III
ND/min.displaced displaced
Lam Cast Mystery
Ratliff Cast IF
Canale Cast IF
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Type III
• Treatment– Nondisplaced:
• cast • follow closely for loss of reduction
– Displaced: • IF• cannulated screws or peds hip screw• avoid physes
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Type III
• Results
• Similar to type II• Nondisplaced Less complications• Outcome in literature is variable• IF reduces coxa vara and nonunion
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M.H.--1 Year f/u
Type III, emergent open reduction (capsulotomy), Richards ped hip screw
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Type III
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Type IV
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Type IV
• Not common (10-15% of peds hip fx)• Fewest complications• AVN still possible, but unusual
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Type IV
• Treatment
• Most agreement between authors• Conservative
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Type IV
• Treatment
• Spica in younger patients• Pediatric hip screw in older pts, or those
with unstable reduction
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Type IV
• Results
• Generally good• Fewest complications
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R.K.R.--14 yo Male
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R.K.R.--ORIF, Tape
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R.K.R.-9 Wks
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R.K.R.--9 Months
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R.K.R.--10 mo, ROH
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R.K.R.--15 Months
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Type IV--13 yo
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Type IV --DHS, Wire
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Type IV--2 Mo Post-op
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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
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TX Highlights• Surgery and implants available now are
different than 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
• Expanded indications in polytrauma pt’s
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Complications
AVN Coxavara
Physisclosure
Non-union
Del.Union
Ratliff 42% 20% 15% 10% 24%
Lam 17% 30% 15% 10%
Canale 43% 21% 62% 6.5%
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AVN
Most common and devastatingcomplication
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AVN
• 40-45% overall rate
• Type I ?, ~100% with dislocation• Type II 50%• Type III 25%• Type IV 10%
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Type II FNF
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Type II FNF – 8 and 10 Mos Postop
Posttraumatic Osteonecrosis and Collapse
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AVN
• Displacement vs. Hematoma
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AVN--Displacement
• AVN higher in displaced fractures
• Gerber: 30% AVN despite early capsulotomy
Displaced NDRatliff 53% 25%Canale 52% 8%
Heiser 17% 0%
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AVN--Hematoma
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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
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AVN--Hematoma
• Ng, Cole. Injury,1996:• 7/23 (30%) in displaced, 2/9 (22%) in ND• Displaced II’s and III’s:
– 6 not decompressed, 3/6 AVN– 10 decompressed, 1/10 AVN
• Literature review: 3/39 (8%) AVN if decompressed early
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AVN
Ratliff 1962
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AVN
• Best form of tx unknown• Results may be no better• Maintain motion• Remove internal fixation
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COXA VARA
• 20-30% incidence• Loss of reduction, closure of proximal
femoral physis• Incidence and amount of deformity
decreased by internal fixation• Gait abnormalities, degeneration• Tx: subtrochanteric osteotomy
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Nonunion
• 5-10% incidence• Less with internal
fixation• Treated by valgus
osteotomy, bone graft, or both
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Physeal Closure
• Variable incidence• Causes: AVN, implants, stimulation• Leg length discrepancy often not
significant, worse with AVN• Tx: contralateral distal femoral
epiphyseodesis
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Summary
• Determine Delbet type and displacement• Treatment and implant will also be
dependent on age• Urgent decompression has theoretical
advantages
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Summary
• Nondisplaced fractures will have less complication and will do better regardless of treatment.
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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
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Summary
• The more proximal the fx, the more likely to get AVN
• Complication rate is high. Counsel the family.
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Hip Dislocations in Pediatric Patients
• Uncommon injury, but more common than femoral neck fractures in children
• Usually posterior• Less commonly associated with fractures
than adults• Results better than in adults Still potential
for osteonecrosis and poor outcome
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Hip Dislocations• Urgent reduction, closed• Adequate anesthesia, relaxation• Careful assessment of
congruity of reduction• If uncertain consider CT scan
to rule out intraarticular fragments
• Open reduction for failure to reduce closed, incomplete reduction with interposed bone or soft tissue
• Protected weightbearing following reduction until full, painless ROM
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Incarcerated Fragment Post Reduction
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Hip Dislocations
• Osteonecrosis rate may be decreased by prompt reduction
• 8-10% incidence after dislocation in skeletally immature
• Delay in reduction, high energy mechanism, and older age are risk factors
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