Hip fractures in children are very rare and generally the result of high- speed motor vehicle accidents. Approximately one third of these fractures historically would result in serious complications including avascular necrosis (AVN) and coxa vara deformity both of which results in progressive pain, leg length discrepancy, and disability. Treatment of a displaced hip fracture requires an experienced pediatric orthopedic surgeon, prompt reduction, internal fixation, and prolonged immobilization to avoid lifetime disability.
Previous reports in the orthopedic literature related to pediatric hip fractures indicated an unacceptable rate of late complications including AVN, coxa vara deformity, non-union, and premature growth plate closure. AVN is the result of vascular supply disruption to femoral head that may or may not involve the growth plates. Cox vara and leg length discrepancy results from premature closure of the growth plate that may cause significant shortening of the extremity.
Aside from AVN of the hip, complications related to hip fractures in children appear most related to initial management and technical aspects of the surgical intervention. Outcome studies indicate that it is both the decision between operative versus non-operative management and the operative skills of the orthopedic surgeon that determine the ultimate outcome. These studies indicate any penetration of the growth plate with operative pins will likely result in premature closure of the growth plates that may lead to coxa vara deformity and leg length discrepancy. Early referral to an experience pediatric orthopedic surgeon within 24 hours is recommended.
Fractures of the femoral neck and head are associated with AVN. Essentially there is no proven treatment for AVN other than surgically dealing with its complications. AVN may lead to leg length discrepancy, coxa vara deformity, and ultimately arthritis. There is a suggestion in the literature that if surgical intervention is necessary to repair a pediatric hip fracture AVN might be prevented by including operative opening of the hip capsule to evacuate an associated hematoma that may decrease pressures in the hip allowing for increased blood flow to femoral neck and head.
Children with displaced femoral neck and head fractures will need anatomic reduction, internal fixation, and strict non-weight bearing with immobilization according to a study by Dr. J. M. Flynn from the Children’s Hospital of Philadelphia (CHOP). This study reported superior results with displaced femoral neck fractures when internal fixation is provided regardless if the hips could be anatomically reduced without surgery. In addition to surgical repair these children were post-operatively placed in a spica cast for six weeks that prevents all movement at the hip and prevents weight bearing. By basically casting the child’s hip guarantees that they remain inactive to prevent movement related disruptions in blood flow to the healing hip. Late complications were reduced significantly.
Appropriate management of childhood hip fractures will likely result in good outcomes even in the case of displaced femoral neck fractures if handled by capable pediatric orthopedic surgeons. An Academic Physician Life Care Planner will be necessary for those with late complications such coxa vara deformity, AVN, and early post-traumatic arthritis since these diagnoses will ultimately require future operative management and medical care to the injured child’s life expectancy. In addition, these children will have psychological, educational, and vocational effects related to their injury that will need to be addressed in the comprehensive life care plan to prevent complications and improve their psychosocial health.
http://www.sciencedirect.com/science/article/pii/S0020138304001731
http://www.bjj.boneandjoint.org.uk/content/84-B/1/108.full.pdf
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.474.503&rep=rep1&type=pdf
