Plain Radiography
Whenever a proximal femoral injury is suspected, an anteroposterior (AP) radiograph of the pelvis with both hips and a cross-table lateral radiograph should be obtained. The radiographs must be carefully examined with a view to determining the presence of fracture, the Delbet type, and the degree of displacement.
Careful examination of the contralateral side on radiographs (or magnetic resonance imaging [MRI] scans) helps detect undisplaced fractures. In patients younger than 18 months with suspected proximal femoral epiphyseal separation, arthrography has been suggested as a diagnostic aid.
For the diagnosis of femoral shaft fractures, plain radiographs are generally adequate (see the image below). The radiographs must be carefully examined for the presence and location of the fracture, its configuration, the degree of displacement, and the degree of comminution. Radiographic examination must include the entire femur, along with the hip and knee, to rule out associated injuries. Appropriate additional studies should be undertaken in patients with multiple trauma, head injuries, and other visceral injuries.
X-ray of adolescent who sustained sporting injury and fractured his right femur. Image courtesy of Dr. Bhavuk Garg, Senior Resident of Orthopedics, All India Institute of Medical Sciences, Delhi.
For the diagnosis of distal femoral physeal injuries, plain AP and lateral radiographs are usually adequate. The radiographs show displacement, widening, or adjacent bony disruption in cases of physeal injury.
Other Imaging Modalities
Type I and type III undisplaced fractures are often overlooked on plain radiography. Stress views were previously recommended for diagnosis, but MRI has become the preferred imaging modality. Computed tomography (CT) is used to determine the degree of displacement and is useful for preoperative planning. In infants, MRI, ultrasonography (US), or arthrography of the knee may be required to make the diagnosis of separation of a relatively unossified femoral epiphysis.
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Arterial supply to head of femur in child.
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Depiction of various Delbet types of proximal femoral injury.
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Patterns of avascular necrosis in hip fractures in children.
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(a) Delbet type I proximal femoral epiphyseal injury. (b) Reduction and fixation with smooth pins. (c) Avascular necrosis 1 year after surgery. (d) Bone scan showing decreased vascularity of femoral head on affected side. (e) Radiograph after pin removal showing avascular necrosis (L) of hip.
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Spiral fracture of femoral shaft, with hypertrophic callus due to previous multiple fractures (a) in 2-year-old abused child treated with spica cast (b), showing union (c).
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(a) Comminuted fracture shaft of femur in adolescent. (b) Insertion of submuscular bridge plate through small distal incision. (c) Screw insertion through tiny stab incisions under imaging guidance. (d) Postoperative check film. (e) Tiny scars 3 months after surgery.
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Depiction of various Salter-Harris types of distal femoral epiphyseal injury.
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Type II distal femoral epiphyseal injury fixed with 2 smooth crossed pins.
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Schematic diagram showing various methods of operative fixation of distal femoral epiphyseal injuries.
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X-ray of adolescent who sustained sporting injury and fractured his right femur. Image courtesy of Dr. Bhavuk Garg, Senior Resident of Orthopedics, All India Institute of Medical Sciences, Delhi.
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Immediate postoperative x-ray of titanium elastic nailing performed on male child. Image courtesy of Dr. Bhavuk Garg, Senior Resident of Orthopedics, All India Institute of Medical Sciences, Delhi.
Tables
Delbet Fracture Type |
Recommended Treatment |
Remarks |
I (transepiphyseal) |
Gentle closed reduction and fixation with 2 or 3 smooth pins, followed by spica cast in abduction and internal rotation for 6-12 wk Repeated attempts at reduction should be avoided Irreducible fractures and fracture dislocations may require open reduction |
These fractures have highest rate of complications and worst prognosis Loss of reduction with varus deformity is frequent Premature physis closure and limb length discrepancy may occur AVN of femoral head is reported in 20-100% of cases |
II (transcervical) |
Gentle closed reduction and fixation with 2 or 3 threaded pins (young children) and 2 or 3 parallel screws (older children), followed by spica cast for 6 wk Implants must stop short of physis Hip decompression by needle aspiration may be added |
Loss of reduction and varus malunion are common if fracture is stabilized by external immobilization alone Decompression is reported to reduce risk of AVN in these cases; AVN is reported in as many as 50% of cases Nonunion is reported in 15% of cases |
III (cervicotrochanteric) |
Closed reduction and internal fixation with Kirschner wires or cannulated screws in all displaced fractures and undisplaced fractures in children >6 y Undisplaced fractures in children < 6 y can be treated with closed reduction and spica cast |
Conservative treatment in older children is associated with high rates of varus nonunion in some series Overall, these fractures have better outcome than type II fractures Reported incidence of AVN is 15-20% |
IV (pertrochanteric or intertrochanteric) |
Closed reduction and internal fixation with Kirschner wires or cannulated screws in all displaced fractures and undisplaced fractures in children >6 y Undisplaced fractures in children < 6 y can be treated with closed reduction and spica cast |
Conservative treatment in older children is associated with high rates of varus nonunion in some series These fractures have best prognosis These are extracapsular fractures and therefore less likely to cause direct vascular insult; reported incidence of AVN is 5% |
AVN = avascular necrosis. |
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Age |
Fracture Treatment |
Treatment |
Remarks |
Infants |
Stable/undisplaced |
Splint |
Suspect abuse or osteogenesis imperfecta Remarkable remodeling potential |
Unstable/angulated |
Pavlik harness, gallows traction, spica cast |
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1-6 y |
Stable fracture |
Immediate spica cast |
Telescope test to determine stability Skeletal traction in older, heavier patients |
Unstable fracture/unacceptable reduction |
Traction followed by spica cast |
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Multiple trauma |
Flexible intramedullary nails/external fixator |
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6-11 y |
Low-energy stable fractures |
Early spica |
Remodeling potential lesser than for younger children Operative stabilization indicated if early mobilization required Flexible intramedullary nailing preferred |
High-energy unstable fracture |
Traction followed by spica/plating/external fixator/flexible nailing |
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≥ 11 y |
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Internal or external fixation; external fixator for comminuted, unstable, and compound fractures |
Operative stabilization preferred Limited remodeling potential Accurate restoration of length and alignment mandatory Rigid nailing through piriformis fossa should be avoided to reduce risk of avascular necrosis |
