Download - Proximal femur fracture in children
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Proximal Femur fracture in pediatrics
Dr. Muhammad BilalResident Trauma & Orthopedic department
PIMS
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Growth centers of proximal femur
Blood supply of head of femur
Fracture classification
Treatment
Complications
INDEX
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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
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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
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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%
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TREATMENT
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TREATMENT
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Avascular necrosis Coxa vara Non-union Limb length discripency Chondrolysis Infection
Complications
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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
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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
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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
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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
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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
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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
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Infection <1% incidence after ORIF or CRPP treatment
◦ debridement, maintain fixation until union may lead to osteomyelitis, AVN,
chondrolysis, premature physeal closure
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