Pediatric proximal femur

Vascular anatomy

The deep branch of the medial femoral circumflex artery provides the main relevant blood supply to the femoral head.

Anterolateral approach

The anterolateral approach to the proximal femur, through the interval between the gluteus medius and minimus muscles and tensor fascia lata, provides access to the hip joint at the lateral proximal femur. This approach is adequate for fracture fixation and application of a plate onto the lateral aspect of the femur.

Lateral via trochanteric flip

Lateral approach via trochanteric flip is a variant of the surgical hip dislocation approach, which is indicated in children for intracapsular fractures when dislocation is not appropriate.

Transgluteal approach

The transgluteal approach to the proximal femur, between the anterior and medial part of the gluteus medius, provides access to the hip joint at the lateral proximal femur.

This approach is adequate for fracture reduction with K-wire, screw or plate fixation and is indicated in the following situations:

• Open reduction and stabilization of extracapsular neck fractures
• Stabilization of nondisplaced but complete intracapsular fractures

Anterior approach

The anterior approach provides the most direct access to the anterior aspect of the hip. Many surgeons prefer this approach for reduction of femoral head and neck fractures.

Lateral approach

The lateral approach is indicated in the following situations:

1. In combination with an anterior approach for the insertion of screws or a pediatric hip locking plate
2. For the open and closed reduction and stabilization of extracapsular fractures
3. For stabilization of nondisplaced intracapsular fractures

Surgical hip dislocation

Surgical hip dislocation is indicated in children for many conditions of the femoral head and femoral head/neck junction, including fractures.

These include:

• Femoro-acetabular impingement
• Slipped capital femoral epiphysis (SCFE)
• Perthes’ disease with subluxation, or hinging
• Acetabular and femoral head fractures, including osteochondral lesions

Surgical hip dislocation provides full visualization of the complete femoral head and acetabulum.

Minimally invasive approach

One great advantage of the ESIN for proximal femoral fractures is that the approach is minimally invasive of the soft tissues, facilitating early joint motion.