Hip fractures in children
- Kimberly P Stone, MD, MS, MA
Kimberly P Stone, MD, MS, MA
- Assistant Professor of Pediatrics
- University of Washington
- Klane White, MD
Klane White, MD
- Associate Professor, Department of Orthopaedics and Sports Medicine
- University of Washington School of Medicine
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."
- Beaty JH. Fractures of the hip in children. Orthop Clin North Am 2006; 37:223.
- McCarthy J, Noonan K. Fractures and traumatic dislocations of the hip in children. In: Rockwood and Wilkins' Fractures in Children, 7th, Beaty JH, Kasser J. (Eds), Lippincott Williams & Wilkins, Philadelphia 2010. p.769.
- Herring JA. Hip fractures. In: Tachdijan's Pediatric Orthopedics: From the Texas Scottish Rite Hospital for Children, 4th, Saunders Elsevier, Philadelphia 2008. Vol 3.
- Mirdad T. Fractures of the neck of femur in children: an experience at the Aseer Central Hospital, Abha, Saudi Arabia. Injury 2002; 33:823.
- Colonna, PC. Fractures of the neck of the femur in children. Am J Surg 1928; 6:793.
- Davison BL, Weinstein SL. Hip fractures in children: a long-term follow-up study. J Pediatr Orthop 1992; 12:355.
- Morsy HA. Complications of fracture of the neck of the femur in children. A long-term follow-up study. Injury 2001; 32:45.
- Pape HC, Krettek C, Friedrich A, et al. Long-term outcome in children with fractures of the proximal femur after high-energy trauma. J Trauma 1999; 46:58.
- Togrul E, Bayram H, Gulsen M, et al. Fractures of the femoral neck in children: long-term follow-up in 62 hip fractures. Injury 2005; 36:123.
- Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg Am 1977; 59:431.
- Ogden JA. Changing patterns of proximal femoral vascularity. J Bone Joint Surg Am 1974; 56:941.
- INGRAM AJ, BACHYNSKI B. Fractures of the hip in children; treatment and results. J Bone Joint Surg Am 1953; 35-A:867.
- Swiontkowski MF, Winquist RA. Displaced hip fractures in children and adolescents. J Trauma 1986; 26:384.
- Canale ST. Fractures of the hip in children and adolescents. Orthop Clin North Am 1990; 21:341.
- Ng GP, Cole WG. Effect of early hip decompression on the frequency of avascular necrosis in children with fractures of the neck of the femur. Injury 1996; 27:419.
- Cheng JC, Tang N. Decompression and stable internal fixation of femoral neck fractures in children can affect the outcome. J Pediatr Orthop 1999; 19:338.
- Song KS, Kim YS, Sohn SW, Ogden JA. Arthrotomy and open reduction of the displaced fracture of the femoral neck in children. J Pediatr Orthop B 2001; 10:205.
- Lam SF. Fractures of the neck of the femur in children. J Bone Joint Surg Am 1971; 53:1165.
- DeFranco MJ, Recht M, Schils J, Parker RD. Stress fractures of the femur in athletes. Clin Sports Med 2006; 25:89.
- Pförringer W, Rosemeyer B. Fractures of the hip in children and adolescents. Acta Orthop Scand 1980; 51:91.
- Moon ES, Mehlman CT. Risk factors for avascular necrosis after femoral neck fractures in children: 25 Cincinnati cases and meta-analysis of 360 cases. J Orthop Trauma 2006; 20:323.
- Flynn JM, Wong KL, Yeh GL, et al. Displaced fractures of the hip in children. Management by early operation and immobilisation in a hip spica cast. J Bone Joint Surg Br 2002; 84:108.
- Newton PO, Mubarak SJ. The use of modified Neufeld's skeletal traction in children and adolescents. J Pediatr Orthop 1995; 15:467.
- Quick TJ, Eastwood DM. Pediatric fractures and dislocations of the hip and pelvis. Clin Orthop Relat Res 2005; :87.
- Stannard JP, Christensen KP, Wilkins KE. Femur fractures in infants: a new therapeutic approach. J Pediatr Orthop 1995; 15:461.
- Forlin E, Guille JT, Kumar SJ, Rhee KJ. Transepiphyseal fractures of the neck of the femur in very young children. J Pediatr Orthop 1992; 12:164.
- Canale ST, Tolo VT. Fractures of the femur in children. Instr Course Lect 1995; 44:255.
- Ramachandran M, Ward K, Brown RR, et al. Intravenous bisphosphonate therapy for traumatic osteonecrosis of the femoral head in adolescents. J Bone Joint Surg Am 2007; 89:1727.
- Heiser JM, Oppenheim WL. Fractures of the hip in children: a review of forty cases. Clin Orthop Relat Res 1980; :177.
- St Pierre P, Staheli LT, Smith JB, Green NE. Femoral neck stress fractures in children and adolescents. J Pediatr Orthop 1995; 15:470.
- Scheerlinck T, De Boeck H. Bilateral stress fractures of the femoral neck complicated by unilateral displacement in a child. J Pediatr Orthop B 1998; 7:246.
- RELEVANT ANATOMY
- MECHANISM OF INJURY
- CLINICAL PRESENTATION AND EXAMINATION
- RADIOGRAPHIC FINDINGS
- INITIAL TREATMENT
- Provisional reduction
- Emergency decompression
- Child protection
- INDICATIONS FOR ORTHOPEDIC CONSULT OR REFERRAL
- DEFINITIVE CARE
- FOLLOW-UP CARE
- RETURN TO SPORT OR WORK
- STRESS FRACTURES OF THE HIP
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS