Annual Report

Executive Editor: Fergal Monsell General Editor: Chris Colton

Authors: Andrew Howard, James Hunter, Theddy Slongo

Pediatric proximal femur 31-E/1.1

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Glossary

General considerations

Complete, unstable proximal femoral fractures carry a significant risk of avascular necrosis (AVN) of the femoral head. AVN can result from entrapping or rupturing the retinacular vessels during a closed reduction maneuver. Decompression of hemarthrosis may reduce the risk of AVN. The focus will, therefore, be on open procedures, which aim to reduce this risk. Detailed knowledge of the vascular supply of the femoral head is a prerequisite for safe treatment and the management of femoral neck fractures in children ideally requires experience in hip surgery.

Hip spica
Main indication Skill Equipment
Stable, incomplete, or virtually nondisplaced fracture in a younger child Some specialized surgical experience Basic equipment only

Further indication

  • Image intensification not available

Contraindications

  • Local soft-tissue compromise
  • Obese patients

Advantage

  • May be performed without anesthesia in selected cases

Disadvantages

  • Less stable than in situ fixation
  • Risk of secondary displacement
  • Patient care requires parental/carer compliance
In situ fixation with K-wires or screws
Main indication Skill Equipment
Stable, incomplete, or virtually nondisplaced fractures Some specialized surgical experience Simple surgical and imaging resources

Contraindications

  • Image intensification not available
  • Reduction required

Advantage

  • Greater stability than hip spica

Disadvantages

  • Risk of implant failure
  • Risk of pathological fracture at implant entry point
  • Requires anesthesia
  • Risk of growth disturbance
  • May require implant removal
Open reduction, K-wire fixation
Main indication Skill Equipment
Displaced fracture in younger children, angular stability not required Highly experienced and skilled surgeon Simple surgical and imaging resources

Disadvantages

  • Less stable than screw or plate
  • Risk of pathological fracture at implant entry point
  • Requires removal of K-wire
  • Risk of implant penetration
  • Risk of implant failure
Open reduction, screw fixation
Main indication Skill Equipment
Displaced fracture in younger children, angular stability not required Highly experienced and skilled surgeon Simple surgical and imaging resources

Contraindication

  • Obliquity of the fracture line and/or size of metaphyseal fragment prevents stable fixation with a screw

Advantage

  • More stable than K-wire

Disadvantages

  • Less stable than plate
  • Risk of pathological fracture at implant entry point
  • Risk of implant penetration
  • Risk of implant failure
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2017-12-04