Fractures and Dislocations about
the Hip in the Pediatric Patient
Joshua Klatt, MD
Original Author: Mark Tenholder, MD; March 2004
Revised:
Steven Frick, MD; August 2006
Harish Hosalkar, MD; April 2011
Joshua Klatt, MD; November 2011

“Hip fractures in children are of interest
because of the frequency of complications
rather than the frequency of fractures.”
 Canale
Femoral Neck Fractures in
Children




Rare fracture
Anatomic and vascular differences
Emergent treatment
High complication rate
Background

Different from Adults
–
–
–
–
–
High-energy
Thick periosteum
Vascularity
Physes
Treatment options
Background

Osseous Anatomy
– Proximal femoral
physis
– Trochanteric
apophysis
– Dense bone
– Small neck
Background

Vascular Anatomy
– Immature
– Variable



Ligamentum teres
Lateral epiphyseal
vessels (bypass physis)
Metaphyseal
circulation (after
physeal closure)
– Vulnerable to injury
Mechanism




MVC
Auto-ped
High falls
Minor trauma can still be a cause
Classification




Type 1 – Transepiphyseal
Type 2 – Transcervical
Type 3 – Cervicotrochanteric
Type 4 - Intertrochanteric
Colonna PC. Fractures of the neck of the femur in
children. Am J Surg 1929;6:793-7.
Type I
Transepiphyseal
Type I



Very rare
Little evidence
High risk of AVN
(up to 100% in some series)
Canale ST, Bourland WL. Fracture of the neck and
intertrochanteric region of the femur in children. J Bone
Joint Surg Am. 1977 Jun.;59(4):431–443.
Type I
Treatment

Nondisplaced
– Can treat with spica cast

Displaced
– Past


Closed reduction and
spica
ORIF
– Present

Closed or open reduction
plus internal fixation
– Threaded pins
– Cannulated screws
– Smooth pins
Forlin E, Guille JT, Kumar SJ, Rhee KJ. Transepiphyseal
fractures of the neck of the femur in very young children.
J Pediatr Orthop. 1992 Feb.;12(2):164–168.
Type I
Results


Recent literature
following better
understanding of hip
vascularity
In some circumstances
the femoral head may not
be completely avascular,
and, with appropriate
surgical care, the hip can
be preserved
Schoenecker JG, Kim Y-J, Ganz R. Treatment of traumatic separation of the
proximal femoral epiphysis without development of osteonecrosis: a report of
two cases. The Journal of Bone and Joint Surgery. 2010 Apr.;92(4):973–977.
Type I
Example


10 yr female
Type I fracturedislocation of hip
Type I
Example

ORIF and Pins Attempted
Type I
Example


Postop film
Malreduced and
dislocated
Type I
Example

Repeat ORIF
Type I
Example

3 month follow-up
Type I
Example


8 Months
Heterotopic ossification evident
Type I
Example


11 Months
Osteonecrosis
Type II
Transcervical
Type II



Most common type
(50% of peds hip fx)
Most common AVN
(50%)
3/4 will be displaced
Type II


Nondisplaced
Displaced
Lam (1971)
Traction/Cast
Traction/CR Cast
Ratliff (1962)
Cast
IF
Canale (1977)
IF
IF
Quick (2005)
IF
CR vs OR with IF
Historical treatment
Internal fixation is currently the treatment
of choice
Lam. Fractures of the neck of the femur in children. J Bone Joint Surg Am. 1971;53:1165–1179.
Ratliff. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962;44-B:528–542.
Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg
Am. 1977;59:431–443.
Quick. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;(432):87–96.
Type II
Treatment

Nondisplaced
– Spica cast, if young
– Use internal fixation,
if older
– If in doubt, treat as
displaced
Type II
Treatment

Displaced
– Anatomic reduction is
important, open if necessary

Do not accept varus malreductions
– Avoid excess traction

Fracture table may be used
without extreme
positioning for prolonged
period
– Cannulated screws/ threaded
pins to compress
– Avoid physis

But stability and reduction is
first priority
Type II
Results

Nondisplaced
– Fewer complications

Outcome in literature
is variable
– AVN in up to 50%


Highest complication
rate of the 4 types
Improved with
internal fixation
İnan U, Köse N, Ömeroğlu H. Pediatric femur neck fractures: a retrospective
analysis of 39 hips. J Child Orthop. 2009 May 26;3(4):259–264.
Type III
Cervicotrochanteric
Type III

Second most common
– 35% of peds hip fx

Second highest AVN
rate
– 25-30%

2/3 displaced
İnan U, Köse N, Ömeroğlu H. Pediatric femur neck fractures: a retrospective
analysis of 39 hips. J Child Orthop. 2009 May 26;3(4):259–264.
Type III
Treatment

Nondisplaced
– Spica cast
– Follow closely for
loss of reduction

Displaced

ORIF
– Cannulated screws
– Peds hip screw

Avoid physes
İnan U, Köse N, Ömeroğlu H. Pediatric femur neck fractures: a retrospective
analysis of 39 hips. J Child Orthop. 2009 May 26;3(4):259–264.
Type III
Results


Slightly better than II
Nondisplaced
– Fewer complications

Outcome in literature
is variable
– AVN in up to 30%

IF reduces coxa vara
and nonunion
Flynn. Displaced fractures of the hip in children. Management by early operation
and immobilisation in a hip spica cast. J Bone Joint Surg Br. 2002;84:108–112.
Type III
Example
6 year old femal
 MVC
 Liver laceration
 Ipsilateral femoral
neck, femur, and tibia
fractures

Type III
Example
Type III
Example




8 wks post-op
Union
Cast removed,
WBAT
No AVN
Type IV
Intertrochanteric
Type IV

Not common
– 10-15% of peds hip fx


Fewest complications
AVN still possible,
but unusual
Type IV
Treatment


Most agreement
between authors
Nondisplaced
– Hip-spica in younger
patients

Displaced
– Pediatric hip screw in
older pts
– Or in those with
unstable reduction
Type IV
Results


Generally good
Fewest complications
– High energy still can
result in AVN (1020%)
Type IV
Example


14 year old male
Motorcycle crash
Type IV
Example
Type IV
Example

9 weeks post-op
Type IV
Example

9 months post-op
Type IV
Example


10 months post-op
After hardware removal
Type IV
Example


15 months post-op
AVN
Hip Fracture
Treatment Highlights

Data on nondisplaced fractures is limited
– Conclusions are difficult


Most nondisplaced fractures can be treated
in a cast
Exceptions
– Older child
– Type II
Hip Fracture
Treatment Highlights


Surgery and implants available now are
different than those used in older literature
More recent emphasis on internal fixation
– Anatomic reduction and compression is key
for successful union


Surgical approach should not further
destabilize blood supply to femoral head
Expanded indications in polytrauma pt’s
Hip Fracture
Complications
AVN
Coxa Vara
Physeal
Closure
Nonunion
Delayed
Union
Ratliff
42%
20%
15%
10%
24%
Lam
17%
30%
15%
Canale
43%
21%
62%
10%
7%
Lam. Fractures of the neck of the femur in children. J Bone Joint Surg Am. 1971;53:1165–1179.
Ratliff. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962;44-B:528–542.
Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in
children. J Bone Joint Surg Am. 1977;59:431–443.
Hip Fracture
AVN
Most common and devastating
complication
Hip Fracture
AVN

6 – 53% overall rate

Type I
Type II
Type III
Type IV



57% to 100%
50%
25%
10%
Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations
of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:87–96.
Hip Fracture
AVN

AVN may develop if
– The vessels are torn in
the initial injury
– The vessels are kinked
at due to displacement
– There is intracapsular
tamponade causing
vascular disruption
– The vessels are not
protected during
healing
Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations
of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:87–96.
Hip Fracture
AVN

Factors influencing rate of AVN
–
–
–
–
–
–
Degree of initial displacement
Timing of reduction and fixation
Quality of reduction
Stability of reduction and fixation
Decompression of capsular hematoma
Weight-bearing status
Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations
of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:87–96.
AVN
Classification
Ratliff 1962
Ratliff A. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962 Aug.;44-B:528–542.
AVN
Risk Factors
Degree of Initial Displacement Timing of reduction
 Nondisplaced
 Less than 24 hours
– None in most series

Displaced
– 43% to 88% rate
-Mirdad. Fractures of the neck of femur in children: an
experience at the Aseer Central Hospital, Abha, Saudi
Arabia. Injury. 2002;33:823.
-Morsy. Complications of fracture of the neck of the
femur in children. A long-term follow-up study. Injury.
2001;32:45.
-Forlin. Transepiphyseal fractures of the neck of the
femur in very young children. J Pediatr Orthop.
1992;12:164.
– 0% to 6%

Greater than 48 hours
– 40%
-Cheng. Decompression and stable internal fixation of
femoral neck fractures in children can affect the
outcome. J Pediatr Orthop. 1999;19:338.
-Flynn. Displaced fractures of the hip in children.
Management by early operation and immobilisation in
a hip spica cast. J Bone Joint Surg Br. 2002;84:108.
-Shrader. Femoral Neck Fractures in Pediatric
Patients. Clin Orthop Relat Res. 2007;454:169.
AVN
Risk Factors
Quality of reduction
 Excellent/anatomic
reduction
– 0% to 17% AVN

Nonanatomic/fair/poor
Capsular decompression
 No decompression
– 50%

Decompression
– 0% to 10%
– 70% to 100% AVN
-Morsy. Complications of fracture of the neck of the
femur in children. A long-term follow-up study. Injury.
2001;32:45.
-Shrader. Femoral Neck Fractures in Pediatric
Patients. Clin Orthop Relat Res. 2007;454:169.
-Cheng. Decompression and stable internal fixation of
femoral neck fractures in children can affect the
outcome. J Pediatr Orthop. 1999;19:338.
-Ng. Effect of early hip decompression on the
frequency of avascular necrosis in children with
fractures of the neck of the femur. Injury. 1996;27:419.
Coxa Vara





20-50% incidence
Loss of reduction, closure of proximal
femoral physis
Incidence and amount of deformity
decreased by internal fixation
Gait abnormalities, degeneration
Tx: Subtrochanteric osteotomy
Eberl. Post-traumatic coxa vara in children following screw fixation
of the femoral neck. Acta Orthop. 2010 Aug.;81(4):442–445.
Nonunion



5-10% incidence
Less with internal
fixation
Treatment
– Valgus osteotomy
– Bone graft
-Bagatur. Complications associated with surgically
treated hip fractures in children. J Pediatr Orthop B.
2002;11:219.
-Quick. Pediatric Fractures and Dislocations of the
Hip and Pelvis. Clin Orthop Relat Res. 2005;432:87.
Physeal Closure




Variable incidence (up to 40%)
Causes: AVN, implants, stimulation
Leg length discrepancy often not
significant, worse with AVN
Tx: Contralateral distal femoral
epiphysiodesis
-Morsy. Complications of fracture of the neck of the femur in
children. A long-term follow-up study. Injury. 2001;32:45.
Summary




Determine Delbet type and displacement
Urgent treatment with reduction and
fixation as needed
Treatment and implant will also be
dependent on age
Joint decompression has theoretical
advantages, and some literature support
but quality of evidence poor
Summary



Nondisplaced fractures will have fewer
complications and will do better regardless
of treatment.
The more proximal the fx, the more likely
to get AVN
Complication rate is high. Counsel the
family.
Summary

Internal fixation is indicated in:
–
–
–
–

Displaced type I
All type II
Types III and IV if displaced or child is older
Polytrauma
Internal fixation may reduce complications
Hip Dislocations





Uncommon, but more common than femoral
neck fractures in children
Usually posterior, rarely anterior
Less commonly associated with fractures than
adults
Results better than in adults
Still potential for osteonecrosis and poor
outcome
Herrera-Soto. Traumatic hip dislocations in children and adolescents:
pitfalls and complications. J Am Acad Orthop Surg. 2009;17:15.
Hip Dislocations





Urgent reduction, closed
Adequate anesthesia,
relaxation
Careful assessment of
congruity of reduction
If uncertain consider
CT/MRI to rule out intraarticular fragments
Protected weight-bearing
following reduction until
full, painless ROM
Hip Dislocations
Treatment

Operative indications
– Delayed treatment
– Irreducible dislocation
– Incongruous or
incomplete reduction
with interposed bone
or soft tissue
Hip Dislocations
Treatment
Open Reduction
 Approaches
– Anterior (Smith-Peterson)
– Anterolateral (Watson-Jones)
– Trans-trochanteric

Avoid posterior to prevent
damage to the blood-vessels
and potentially-preserved
vascularity of the femoral
head
Trochanteric flip approach
Hip Dislocations
Complications

Complications
–
–
–
–

Avascular necrosis (8-20%)
Myositis ossificans (8-15%)
Sciatic nerve palsy
Early secondary arthritis
Factors predisposing to poor result:
–
–
–
–
–
Older child
Severe trauma
Delay in reduction (> 8 hours)
Incongruous reduction
AVN
Herrera-Soto. Traumatic hip dislocations in children and adolescents:
pitfalls and complications. J Am Acad Orthop Surg. 2009;17:15.
Hip Dislocations
Summary






Early diagnosis and prompt reduction
Important to recognize associated fracture/
inadequate reduction
Advanced imaging may be necessary
Surgical approach should not further
compromise blood supply
AVN is still a significant risk with 8-20%
incidence in skeletally immature
Delay in reduction, high energy mechanism, and
older age are risk factors
Herrera-Soto. Traumatic hip dislocations in children and adolescents:
pitfalls and complications. J Am Acad Orthop Surg. 2009;17:15.
Hip Dislocations
Example 1
Hip Dislocations
Example 1
Hip Dislocations
Example 1
Hip Dislocations
Example 1
After anterolateral open reduction
Hip Dislocations
Example 2
12 yr male with reduced hip dislocation and increased medial joint space
Hip Dislocations
Example 2
Inadequate reduction due to interposition
Hip Dislocations
Example 2
Open surgical dislocation: Trochanteric flip approach
Hip Dislocations
Example 2
Intra-articular loose tissue (post-labral piece)
Hip Dislocations
Example 2
6 month follow-up
Hip Dislocations
Example 2
15 month follow-up. No evidence of AVN.
Bibliography










Bagatur AE, Zorer G. Complications associated with surgically treated hip fractures in children. J
Pediatr Orthop B. 2002 Jul.;11(3):219–228.
Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J
Bone Joint Surg Am. 1977 Jun.;59(4):431–443.
Cheng JC, Tang N. Decompression and stable internal fixation of femoral neck fractures in children
can affect the outcome. J Pediatr Orthop. 1999 Apr.;19(3):338–343.
Colonna PC. Fractures of the neck of the femur in children. Am J Surg 1929;6:793-7.
Eberl R, Singer G, Ferlic P, Weinberg AM, Hoellwarth ME. Post-traumatic coxa vara in children
following screw fixation of the femoral neck. Acta Orthop. 2010 Aug.;81(4):442–445.
Flynn JM, Wong KL, Yeh GL, Meyer JS, Davidson RS. Displaced fractures of the hip in children.
Management by early operation and immobilisation in a hip spica cast. J Bone Joint Surg Br. 2002
Jan.;84(1):108–112.
Forlin E, Guille JT, Kumar SJ, Rhee KJ. Transepiphyseal fractures of the neck of the femur in very
young children. J Pediatr Orthop. 1992 Feb.;12(2):164–168.
Herrera-Soto JA, Price CT. Traumatic hip dislocations in children and adolescents: pitfalls and
complications. J Am Acad Orthop Surg. 2009 Jan.;17(1):15–21.
İnan U, Köse N, Ömeroğlu H. Pediatric femur neck fractures: a retrospective analysis of 39 hips. J
Child Orthop. 2009 May 26;3(4):259–264.
Lam SF. Fractures of the neck of the femur in children. J Bone Joint Surg Am. 1971 Sep.;53(6):1165–
1179.
Bibliography







Mirdad T. Fractures of the neck of femur in children: an experience at the Aseer Central Hospital,
Abha, Saudi Arabia. Injury. 2002 Nov.;33(9):823–827.
Morsy HA. Complications of fracture of the neck of the femur in children. A long-term follow-up
study. Injury. 2001 Jan.;32(1):45–51.
Ng GP, Cole WG. Effect of early hip decompression on the frequency of avascular necrosis in
children with fractures of the neck of the femur. Injury. 1996 Jul.;27(6):419–421.
Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop
Relat Res. 2005;(432):87–96.
Ratliff A. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962 Aug.;44-B:528–
542.
Schoenecker JG, Kim Y-J, Ganz R. Treatment of traumatic separation of the proximal femoral
epiphysis without development of osteonecrosis: a report of two cases. J Bone and Joint Surg. 2010
Apr.;92(4):973–977.
Shrader MW, Jacofsky DJ, Stans AA, Shaughnessy WJ, Haidukewych GJ. Femoral Neck Fractures in
Pediatric Patients. Clin Orthop Relat Res. 2007 Jan.;454:169–173.
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