FRACTURE NECK OF

FEMER
Dr Mumtaz Hussain
Assistant Professor
Department of Pediatric Orthopedics
The Children’s Hospital & The Institute
of Child Health Lahore
Epidemiology
account for <1% of all fractures in pediatric patients
<1% of all hip fractures

 Boardman M, Herman M, Buck B, Pizutillo P. Hip Fractures in Children. JAAOS. 2009;17:162-

173.
GROWTH CENTERS OF PROXIMAL FEMER
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
 injury to the GT apophysis leads to shortening of the GT and
coxa valga
overgrowth of the GT apophysis leads to coxa vara
BLOOD SUPPLY
 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
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
 Delbet Classification
Type Description Incidence AVN Nonunion

Type I Transphyseal (IA, <10% 38%

withoutdislocation of epiphysis from
acetabulum; IB, with dislocation of epiphysis)
Type II Transcervical 40-50% 28% 15%
Type III Cervicotrochanteric 30-35% 18% 15-20% (or
basicervical)
Type IV Intertrochanteric 10-20% 5% 5%
TREATMENT
NON OPERATIVE
Spica cast in abduction, weekly radiographs for 3 wks
Indication:
Type IA, II, III, IV nondisplaced, age <4 yrs
TREATMENT
Close reduction internal fixation(CRIF), Per
cutaneous pinning (CRPP)
Indication:
Type II, III, IV, displaced, older child
Open reduction internal fixation(ORIF)
Indication:
Type IB
Pediatric hip screw/ DHS
Indication:
Type IV
TREATMENT
ORIF & Capsulotomy and joint aspiration
 Indication:
 Open hip fracture
 Major Vessel injury
 Concomitant hip dislocation, significant displacement
 Type I
Complications
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 <115deg)
2nd most common complication
more common if fracture is treated nonoperatively
more common for types I, II and III
◦ incidence 25% for type III
Complications
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
Delbet III with nonunion

Pre op post op 3 months postop

Complications
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
Complications
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
Complications
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
Complications
Infection
<1% incidence
after ORIF or CRPP
Treatment
 debridement, maintain fixation until union
may lead to osteomyelitis, AVN, chondrolysis,
premature physeal closure
Delbet type II

Pre op 6wks postop 1 yr postop

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