Proximal femur fracture in children
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Transcript of Proximal femur fracture in children
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
THANK YOU