1. PAEDIATRIC FRACTURE NECK OF
FEMUR

2. < 1% of all pediatric #
<1 % of prevalence of hip # in adults.
Exceedingly rare.

3. Difference from adult
Anatomy
Proximal femoral epiphysis is at a risk of fracture
Orientation of trabeculae in femoral neck in children is not
along the stress lines
Smooth Fracture surfaces, with very little interlocking
impaction  closed reduction less stable.

4. Blood vessels to the femoral head are easily damaged, and a
high incidence of AVN occurs in fractures in children than
adults.
Growth arrest in the physis can cause shortening of up to
15% of the total extremity
 Varus or valgus angulation of the femoral neck also can
occur from arrest of only one side of the physis.

5. A child can tolerate immobilization much more readily than
an adult, and thus more choices for treatment are available,
including traction, a spica cast, and bed rest, in addition to
operative treatment.
Fixation devices causes growth arrest.

6. MECHANISM OF INJURY
Axial loading, torsion, hyperabduction or a direct blow
injury.
Severe high energy trauma.
Proximal femur in children is extremely strong
Fracture after minor injury suggests weaker bone.
Bone cysts, infection.

7. Applied Anatomy
During early childhood only a single proximal femoral physis
exists.
During I yr of life medial portion grows faster creating long
neck.
PFE begins to ossify at 4 – 6 months.
Trochanteric apophysis – 4 yrs.
PFP  metaphyseal growth of the neck
Fusion of physis  14 – 16 yrs.

8. VASCULAR ANATOMY

9. Ligamentum teres little B.S
At birth Metaphyseal vessels predominate.
Gradually diminish as physis develops.
[barrier], non existent by 4 yrs.
Lateral epiphyseal vessels – posterosuperior &
posteroinferior branches of MCFA
At intertrochanteric groove, MCFA branches in to the
retinacular arterial system.

10. Capsulotomy does not damage B.S but violation of IT notch
or LACV  avascular.
At 3-4 yrs, lateral posterosuperior vessels appear to
predominate.
PI & PS vessels persists through out life.
Multiple small vessels coalesce with age.

11. Confluence of GT physis with capital femoral epiphysis along
the superior femoral neck & unique vascular supply to CFE
makes immature hip vulnerable to growth derangement &
subsequent deformity after a fracture.

12. DELBET CLASSIFICATION
TYPE I : Transepiphyseal separation
I A : With dislocation
II B: With out dislocation.
TYPE II : Transcervical fracture
TYPE III : Cervicotrochanteric fracture.
TYPE IV : Intertrochanteric fracture.

13. TYPE 1

14. TYPE 1 TRANSEPIPHYSEAL – through
the physis

15. High energy trauma
8 % of NOF
In a new born during a difficult breach delivery [proximal
femoral epiphysiolysis] mistaken with DDH.
During CR of traumatic dislocations hip.
50% @ with dislocation of CFE.(100% complication)
 < 2 yrs of age better prognosis.
 AVN unlikely but other comp, can occur.

16. TYPE 2

17. TYPE 2 TRANSCERVICAL- through
neck

18. 46% of # NOF
Most common type
Difficult to treat in spica.
70% displaced at presentation
Incidence of AVN related to initial displacement.
AVN  50% [ common comp].

19. TYPE 3

20. TYPE 3 CERVICOTROCHANTERIC –
base of neck

21. Located at or above anterior IT line.
2 nd most common.
34% of NOF #
AVN 20-30%
Premature physeal closure  25%.
Coxa vara  14%.

22. TYPE 4 INTERTROCHANTERIC

23. 12 % of NOF #.
Lowest complication rate
Good healing.
Nonunion & AVN rare.

24. Type 1 # in neonate
Exceedingly rare
A strong suspicion, [F.H not visible] pseudoparalysis &
shortening – key for diagnosis.
holds the limb in flexed, abducted & ext. rotated.
DD – septic arthritis & hip dislocation.
High riding PF metaphysis.
USG.

25. Clinical features
Pain in the hip
Shortened & externally rotated limb.
Non displaced #  walk with limp.
INVESTIGATIONS:
X ray pelvis AP & Cross table lateral view.
Any Break or offset of bony trabeculae near Ward’s triangle
 impacted #.

26. Radioisotopic bone scan  48 hrs after onset, increased
uptake in # site.
MRI  detects # with in first 24 hrs.

27. TREATMENT type -I
Based on age & fracture stability after reduction.
< 2 yrs with minimally displaced #, CR & spica cast
application.
# tends to displace in to varus & ext.rotation, limb should be
in mild abduction & neutral rot.
Displaced # reduced by gentle traction, abduction & IR.

28. < 6-8 Yrs smooth pins
> 8 Yrs  cannulated cancellous screws
Older children should undergo fixation even undisplaced.
Postop spica must in all except for adolescents.
Implants removed shortly # healing [8-12 wks]

29. TYPE 1 B
One attempt CR, if not immediate OR from the side of
dislocation.
Generally posterolateral approach.

30. TYPE II & III
Anatomic reduction & stable IF always indicated to minimize risk
of complications.
Non displaced type 2 # in children < 5 yrs  spica, wants close
follow-up.
Open reduction  Watson & Jones approach
Screws to be inserted short of physis.
If not good purchase penetrate the physis.
Treatment of # is priority, growth disturbance & LLD are
secondary,

32. TYPE IV
Good results with traction & spica, regardless of
displacement.
Indications for IR
- failure to maintain reduction
- polytrauma
- older children
Pediatric hip screw.

33. SURGICAL TIPS
Always predrill & tap before inserting screws.
Avoid crossing the physis but cross it if necessary for
stability.
Postop, hip spica for 6-12 wks if < 10 yrs,

34. COMPLICATIONS:-
Avascular necrosis
Most serious & most frequent
Overall prevalence 30%.
Primary cause of poor results.
Highest after type IB, II, III.
Initial # displacement, damage to blood vessels, #
hematoma.

35. RATLIFF CLASSIFICATION
TYPE I : Involvement of whole head
- most severe & most common form
- poorest prognosis
-damage to all lateral epiphyseal vessels
TYPE II: Partial involvement
- localized damage to one or more LEV.
TYPE III: an area of AVN from # to physis
- damage to superior metaphyseal V.
- rare but good prognosis.

37. X ray ; as early as 6 wks, decreased density of FH with
widening of jt space.
Can develop as late as 2 yrs, so all pt to be followed for
atleast 2 yrs.
Tc bone scan
MRI; no AVN with in 6 wks ,it is unlikely to occur.

38. Late stage

39. COXA VARA
20-30% prevalence
Lower in internal fixed pts.
causes: malunion, AVN, premature physeal closure or a
combination of above.
Raises GT in relation to FH causing shortening of extremity
& abductor lurch.
Subtrochanteric valgus osteotomy if C.vara persists > 2 yrs.
[>110*, in > 8 yrs]

40. PREMATURE PHYSEAL CLOSURE
28% of #
Risk increases with penetration of fixation devices or when
AVN
M.F after type II or III AVN.
Shortening not significant except in younger
Trochanteric epiphysiodesis – progressive coxa vara.

41. NON UNION
7% of #
Not seen after type 1 & IV
Primary cause – failure to obtain or maintain reduction.
If the child had pain & no bridging new bone at 3 months
post injury.
Subtrochanteric valgus osteotomy / rigid IR +/- bone
grafting.

42. others
Infections [1%]
Chondrolysis [ hardware placed inside Jt].

43. STRESS FRACTURE
 Repetitive cycle loading of hip by new or increased
activity.
 Adolescent female athlete, anorexia nervosa, &
osteoporosis.
 X rays only reveal after 4-6 wks
 DEVAS classification
1. Compression - non wt bearing, coxa vara.
2. Tension – inherently unstable, insitu fixation