Transepiphyseal fracture of the femoral neck with dislocation of the femoral head and fracture of the posterior column of the acetabulum in a child

Fractures of the Proximal Femur in Childhood: A Review

BACKGROUND

Femoral neck fractures in children are rare injuries, occurring due to high-energy trauma. Due to the unique anatomy and blood supply of the proximal femur in growing children, these fractures are notorious for high rates of complications despite appropriate management. Classification of these fractures is according to the Delbet system, which not only guides management but also gives prognostic clues. Multiple fixation methods have been described and there is no consensus on what constitutes the best treatment. Osteonecrosis, non-union, coxa vara and premature physeal arrest are the most frequent complications.

PURPOSE

To review the current knowledge, discuss controversial aspects, and provide suggestions for future research.

METHODS

We have reviewed the literature on paediatric proximal femur fractures and have provided an evidence-based guide to the diagnosis and management of these injuries. Common complications have been elaborated and options for their prevention and/or management discussed.

CONCLUSION

There is universal agreement that anatomic reduction and stable internal fixation, supplemented by spica immobilization in younger children, are essential to obtain good outcomes. The role of capsular decompression, choice and configuration of implant, and appropriate timing of surgery are aspects that continue to be debated. Multicenter prospective studies are necessary to standardize treatment of these challenging injuries.

A case report of the management and the outcome of a complete epiphyseal separation and dislocation with left anterior column fracture of the acetabulum

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A case of a child with hip dislocation and acetabular fracture is presented.

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The patient underwent reduction and internal fixation with two cannulated screws.

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Osteonecrosis of the femoral head was evident after six months.

Introduction

Femoral head and neck fractures in children are uncommon, accounting for fewer than 1% of all pediatric fractures and fewer than 8% of all hip fractures. Furthermore, traumatic transphyseal hip fracture is rare to present in daily practice especially when associated with an acetabular fracture.

Presentation of the case

A twelve years old boy, not known to have any chronic illnesses, presented to the emergency department as a case of polytrauma after a road traffic accident. Signs of left hip dislocation were discovered upon physical examination. X-rays and CT scans, revealed a complete transphyseal posterior dislocation and a left anterior column fracture of the acetabulum with a minimal displacement. Within five hours, the patient underwent open reduction and internal fixation by two cannulated screws. The acetabular fracture was managed conservatively. After six months, there were clear signs of osteonecrosis of the femoral head.

Discussion

A high-energy trauma in children and adolescents can lead to simultaneous epiphyseal and acetabular fractures which are associated with a poor prognosis. The age seems to play a role as patients older than ten years have a higher risk of developing AVN after sustaining a hip dislocation regardless of the time of intervention.

Conclusion

Epiphyseal fracture with dislocation of the femoral head is rare among children and adolescents, especially when associated with an acetabular fracture. AVN in such cases can develop, and it represents a challenge to orthopedic surgeons due to the poor prognosis and the future functional limitations of the joint.

Pediatric transepiphyseal seperation and dislocation of the femoral head

Pediatric hip fractures and dislocations are rare in practice and are related to high-energy trauma. The incidence of postoperative avascular necrosis is increasing, especially in the case of transepiphyseal fractures. Surgery is the most common form of treatment, and its timing is important for prognosis of the fracture. Patients and their families should be informed about the possibility of avascular necrosis and further complications related to the fracture.

Surgical treatment of an acetabular fracture and labral tear with suture anchors in a 10-year-old child

This article presents a case of a 10-year-old boy with a right acetabular fracture secondary to a direct blow to the pelvis and back. He sustained a right hip dislocation and transverse with posterior wall acetabular fracture with a nonconcentric hip joint after reduction. The fracture was treated with right labral and articular segment absorbable suture tie-down and relocation of the right hip into an anatomical position. At 32-month follow-up, the patient had returned to activities of daily living, he had a normal and symmetric gait pattern, and no pain on hip adduction, flexion, or internal rotation. This technique reduced the fracture and labrum, relocated the hip joint, and obviated the need for hardware removal that is typically needed in the pediatric population. This case is distinctive due to the patient's young age and treatment method, which has not been described previously for the treatment of this rare pediatric fracture.

Risk factors for avascular necrosis after femoral neck fractures in children: 25 Cincinnati cases and meta-analysis of 360 cases

PURPOSE

Avascular necrosis (AVN) is one of the most serious complications of femoral neck fractures in children. Variability in the reported rates of AVN and lack of statistical evidence has minimized the prognostic power of individual studies. The purpose of our study was to review our own cases as well as those from the literature in an effort to identify the risk factors for AVN.

METHODS

We conducted a computerized search of medical records to identify all children with femoral neck fractures treated at our institution from 1980 to 2003. Records were reviewed to determine fracture type (Delbet type I to IV), displacement, age, treatment, and incidence of AVN. A structured search of PubMed was also performed to identify all reports published in English, on femoral neck fractures in children, from 1965 to 2003. Hand searches of major orthopedic journals and reference lists of publications identified additional cases. Of the 275 citations initially identified through our computerized search, 47 met the criteria for further evaluation. These citations were reviewed by 2 investigators, and data was abstracted from 20 reports that provided patient-level data and met our criteria for inclusion.

RESULTS

Twenty-four patients with 25 femoral neck fractures from our institution were identified including 12 boys and 12 girls with an average age of 8 years (range 1.5 to 16). Over 300 patients who met our study criteria were also identified from the literature, and a total of 360 patients were included in the analysis. Fracture type, displacement, age, and treatment were all statistically significant independent predictors of AVN with P values <or=0.05. With logistic regression analysis, however, fracture type and age were identified as the only significant predictors of AVN. Older children were 1.14 times more likely to develop AVN for each year of increasing age. Type I to III fractures were 15, 6, and 4 times, respectively, more likely to develop AVN than type IV fractures. AVN rate by Delbet class was I=38%, II=28%, III=18%, and IV=5%.

CONCLUSION AND SIGNIFICANCE

Although several factors may contribute to the development of AVN, our meta-analysis provides statistical evidence that fracture type and age are the most significant predictors.

Transphyseal fracture-dislocation of the femoral neck: a case report and review of the literature

We describe a case of transphyseal hip fracture-dislocation in a 7.5-year-old patient who was treated initially by open reduction and internal fixation. Soon after the injury, the femoral head developed avascular necrosis. The treatment was focused on maintaining adequate hip range of motion and providing femoral head containment with a combined subtrochanteric femoral osteotomy and shelf acetabuloplasty. The patient's young age and good hip remodeling potential contributed to the favorable clinical outcome 3 years after the injury. The long-term prognosis remains guarded, however.