Clean FRCS notes with inline figures
Paediatric fracture hip
Radiographic description
•Basal neck of femur fracture in skeletally immature patient, minimally displaced in this view (see cross table lateral Xray)
•Hx: mechanism of injury (ATLS), r/o fracture in same limb, nerve injury
•Surgical emergency in Delbet type 1-3 to decreased AVN risk
Vascular anatomy in difference age
•<4 y.o.: MFCA (lateral epiphyseal artery), LFCA, metaphyseal artery
•4-10 y.o.: MFCA (lateral epiphyseal artery), metaphyseal artery blocked by physis, LFCA regresses
•10-14 y.o.: MFCA (lateral epiphyseal artery), ligament teres artery further regress artery
•>14 y.o. MFCA (lateral epiphyseal artery), metaphyseal artery (anastomosis of metaphyseal and epiphyseal artery re-developed)
Delbet Classification and (AVN risk)
| Type / group | Definition / note |
|---|---|
| 1 | Transphyseal (40%, 100% if dislocation of epiphysis from acetabulum) |
| 2 | Transcervical (30%) |
| 3 | Basal neck (20%) |
| 4 | Trochanteric (5%) |
Treatment
•*** r/o NAI in non walking child
•Conservative: <4 y.o. + undisplaced → hip spica cast
Operative:
Indication: Displaced fracture or >4 y.o.
•ORIF for dislocated transphyseal fracture, otherwise CR + pinning/ screw/ DHS
Fixation:
•Transphyseal pin (for Type 1 fracture or proximal type 2 with minimal metaphyseal bone for anchorage) → Consider post op hip spica if young
•Physeal sparing screws for type 2-4 + young
•Transphyseal screws (near skeletal maturity + need more proximal purchase for stable fixation)
•Avoid posterior cortex protrusion → vascular injury
•Type 4 can fix with paediatric DHS / locking hip plate
•+ Capsulotomy in type 1-3
Postop rehab
•TTWB minimal 6 weeks
•Progression to FWB 6-12 weeks
Return to activity: when radiographically healed
•Removal of implant: old no, young yes
•Need long term FU for physeal arrest and AVN
Complication
•AVN
Risk factor:
3-8 y.o. (Pure MCFA blood supply)
•Delbet type (40/30/20/5)
Ratliff classification
•I complete head – epiphyseal artery (all), worst prognosis
•II partial epiphysis – limited epiphyseal artery
•III between physis and fracture line – superior metaphyseal artery, best prognosis
•Coxa vara (neck shaft angle <130 deg) due to malunion
Treatment depends on age
•<3 y.o.: likely remodel
•<8 y.o.: trochanteric apophysis growth arrest
•Older + trendelenberg gait: Valgus osteotomy
•Coxa valgus in type 4 fracture
•Physeal arrest + LLD
•Chondrolysis