An unexpected diagnosis in a child. I was shocked and intrigued at the same time.
As a Doctor in the early years of your orthopaedic training you become very familiar with the type of patients that get hip fractures. They are discussed in Trauma meetings, you have admitted them when you are on-call and managed their medical problems on the ward. In terms of pattern recognition, hip fractures belong to elderly patients and that is established.
Until you work in a Paediatric hospital or a Paediatric Trauma unit and realise that hip fractures can occur in children. But do not despair some of the knowledge you've acquired for adult hip fractures is relevant, although there are a few exceptions to the rules. Let me explain.
Differences
- Paediatric hip fractures are rare
- These are usually high energy injuries and may be part of a polytrauma
- Remember Non-accidental Injury(NAI) must be excluded
- Paediatric patients often have a physis that can be damaged by the injury or the surgery leading to growth arrest/angular deformity
- Below the age of 4 the ligamentum teres blood supply is more important, whilst above 4 the medial femoral circumflex artery dominates
- Metaphyseal vessels may also contribute to blood supply to the femoral head
Similarities
- Blood supply may be compromised leading to avascular necrosis of the femoral head
Diagnosis is similar to adults but most people would be inclined to do an MRI rather than a CT Scan due to the reduced ionising radiation exposure.
There is also a different classification system. This is the Delbet classification
Unlike most other classifications systems
The higher the number the lower the risk of avascular necrosis
Controversies
Most people would agree that this is an emergency and that operative intervention is needed in order to reduce the risks of avascular necrosis and non-union.
⏱️ Timing? Should this be done in the middle of the night or first thing in the morning?
😕 Who should do it?
🛠️ How to fix it? Is there a role for non-operative management? Should your fixation device cross the physis?
Look forward to seeing your comments below