Displaced fractures of the hip in children

Abstract

Fractures of the hip in children have been associated with a very high rate of serious complications including avascular necrosis (up to 47%) and coxa vara (up to 32%). Over a period of 20 years, we have treated displaced fractures by early anatomical reduction, internal fixation and immobilisation in a spica cast to try to reduce these complications.We have reviewed 18 patients who had a displaced non-pathological fracture of the hip when under 16 years of age. Their mean age at the time of the injury was eight years (2 to 13). They returned for examination and radiography at a mean follow-up of eight years (2 to 17). Each patient had been treated by early (t 24 hours) closed or open reduction with internal fixation and 16 had immobilisation in a spica cast. By Delbet's classification, there was one type-I, eight type-II, eight type-III, and one type-IV fractures. There were no complications in 15 patients. Avascular necrosis occurred in one patient (type-III), nonunion in one (type-II, one of the two patients who did not have a cast) and premature physeal closure in one (type-I). There were no cases of infection or complications as a result of the cast.Our treatment of displaced hip fractures in children by early reduction, internal fixation, and immobilisation in a spica cast gave reduced rates of complications compared with that of large published series in the literature. Unlike adults, healthy children rarely sustain a fracture of the femoral neck the incidence of which is less than 1% of all paediatric fractures.1 It is usually the result of highenergy injury. Previous studies have reported a high rate of complications, including avascular necrosis, coxa vara, premature physeal closure, nonunion and infection.

Fractures of the Proximal Femur in Childhood: A Review

“…In small children (< 10 years), attempts should be made to spare the physis by using screws stopping short of it or by using smooth Kirschner wires where spanning the physis is unavoidable [1]. All such children must be placed in a hip spica post-operatively to protect the internal fixation [5,23,33]. Achieving fracture stability is the most important goal of treatment, however, and trans-physeal fixation provides the most stability.…”

“…Most recently, Bukva et al [32] found significantly lower incidence of AVN and better final outcomes with hip decompression; with needle aspiration and open drainage being equally effective. Contrarily, several authors have reported no significant difference in rates of AVN with and without decompression [21,22,33,38,39]. Interpretation of various reports is difficult as there are a number of confounding factors affecting the incidence of AVN, such as fracture type, displacement, time to surgery, fixation type etc.…”

“…Although most studies agree that earlier surgery leads to better outcomes [9,32,33,39,41], there is no consensus on how early surgery must be done to avoid complications. Studies have defined 'early treatment' variably as within 12, 24, 48 h and even 7 days from the injury [9,32,33,41,42].…”

“…Although most studies agree that earlier surgery leads to better outcomes [9,32,33,39,41], there is no consensus on how early surgery must be done to avoid complications. Studies have defined 'early treatment' variably as within 12, 24, 48 h and even 7 days from the injury [9,32,33,41,42]. A recent meta-analysis found no significant difference in AVN rates between early vs late treated cases (defined as < 24 and > 24 h from injury respectively) [42].…”

Current controversies in management of fracture neck femur in children: A review

“…Literature suggests implant removal at an average of 12 months (9e22 months) after fixation in presence of satisfactory union. 23,40,41 This is due to the fact that screw removal becomes difficult with time and it is difficult to manage a secondary fracture with implant in situ. However, it is not considered a necessity by others as burden of additional surgery increases the cost and morbidity to patient.…”