Hip fractures, also known as proximal femoral fractures, are much less common in children as compared with adults, accounting for <1 percent of all pediatric fractures [1-4]. Their importance lies not with their frequency but with the significant complications that arise from these injuries, especially avascular necrosis of the femoral head. Pediatric hip fractures are considered true surgical emergencies. All such injuries should be managed emergently by an orthopedist, preferably a pediatric orthopedist or one skilled with the particular concerns of the pediatric femur.
This topic will review issues related to hip fractures (proximal femur and femoral neck fractures) in children. Slipped capital femoral epiphysis (SCFE) and femoral shaft fractures in children are discussed separately (see "Evaluation and management of slipped capital femoral epiphysis (SCFE)" and "Femoral shaft fractures in children").
Pediatric hip fractures can be divided into four types as first described by Delbet (figure 1) [1-3,5]. This classification, along with other factors, helps determine operative versus nonoperative therapy and predicts the risk of avascular necrosis of the femoral head . (See 'Complications' below.)
- Type I: Transepiphyseal – These are fractures through the proximal femoral physis, and represent Salter-Harris type I fractures of the proximal femur . Subtypes are IA (without dislocation) and IB (with dislocation) (figure 1). These are the least common types of hip fracture in children, accounting for <10 percent of these fractures [1,3,7-9]. Transepiphyseal fractures occur more commonly in young children and infants. In neonates they are equivalent to "proximal femoral epiphysiolysis," resulting from difficult delivery [1,3]. These fractures are also associated with femoral head dislocations . In children under two years of age, the presence of a transepiphyseal fracture should prompt an evaluation for nonaccidental trauma when a history of trauma is lacking or of insufficient force to explain the degree of injury.
- Type II: Transcervical – This most common type of pediatric hip fracture extends through the mid-portion of the femoral neck and is found in 40 to 50 percent of children [1,3,4,6-10].
- Type III: Cervicotrochanteric – This fracture occurs through the base of the femoral neck and is seen in 25 to 35 percent of children with hip fractures [1,3,4,6-10].
- Type IV: Intertrochanteric – This fracture between the greater and lesser trochanters accounts for 6 to 15 percent of all pediatric hip fractures and has the best outcome [1,3,7,10].
Type II and type III fractures are both subtypes of pediatric hip fractures known as "femoral neck fractures."