Bone and Joint Surgery

Transcription

1 The Journal of Bone and Joint Surgery American Volume VOLUME 59-A, No. 4 JUNE 1977 Fracture of the Neck and Intertrochanteric Region of the Femur in Children* BY S. TERRY CANALE, M.D.t, AND WILLIAM L. BOURLAND, M.D.t, MEMPHIS, TENNESSEE From the Campbell Foundation and the Department of Orthopaedic Surgery. School of Medicine, University of Tennessee Center for the Health Sciences, Memphis ABSTRACT: End-result evaluations after an average follow-up of seventeen years are reported in sixty-one cases (sixty patients). There were five Type-I (transepiphyseal), twenty-seven Type-Il (transcervical), twenty-two Type-Ill (cervicotrochanteric), and seven Type-IV (intertrochanteric) femoral fractures. The majority of Type-I, Type-Il, and displaced Type-Ill fractures were treated with closed or open reduction and -pin fixation. The majority of undisplaced Type-Ill and Type-IV fractures were treated with abduction plaster spica casts. Fifty-five per cent were found to have good results while 20 per cent were fair and 25 per cent, poor. The incidence of complications - avascular necrosis, coxa vara, premature epiphyseal closure, infection, and non-union - was compared with that in previously reported series. The use of -pin fixation appeared to reduce the complications of non-union and coxa vara. Avascular necrosis caused most of the poor results. However, younger children with avascular necrosis obtained better results than did older ones. Some children with results graded as poor roentgenographically were only mildly symptomatic. In 1953, Ingram and Bachynski described the results of treatment in twenty-four children with fractures of the neck of the femur seen at the Campbell Clinic. The present report is an extension of that study expanded with additional cases. Our purposes are: first, to describe the long-term results of a large series of patients treated by the methods originally recommended; second, to determine from the results whether the methods of treatment advocated are still applicable twenty-four years later; and * Read at the Annual Meeting of The American Academy of Orthopaedic Surgeons, Las Vegas, Nevada, February 6, Campbell Clinic, 869 Madison Avenue, Memphis, Tennessee Please address reprint requests to the Campbell Foundation Library. finally, to describe the natural history and sequelae of the complications following fracture of the proximal end of the femur in children as noted on long-term review. Clinical Material Since 1922 at the Campbell Clinic, sixty-nine fractures of the hip in children have been treated or seen in consultation. Utilizing the follow-up methods described by Chung, we were able to re-examine sixty of these patients (sixty-one fractures). Twenty-nine fractures occurred in girls and thirty-two, in boys. Twenty-five fractures were of the right hip and thirty-six, of the left hip. The average age of the patients at fracture was 9.7 years (range, 0.5 to seventeen years). Fifty-five fractures were secondary to severe trauma and six were secondary to minor trauma. Two patients had residua of poliomyelitis in the involved extremity. Pathological fractures were excluded. Primary treatment was instituted at the Campbell Clinic in forty-seven patients. For various reasons, four patients were seen in consultation within four weeks after primary treatment had been instituted elsewhere and nine patients were seen in later consultation for complications. The average length of follow-up was 17.0 years (range, three to fifty-three years), and the average age at follow-up was 26.8 years. Twenty-five of the patients had a follow-up of over twenty years and ten, of over thirty years. Eighteen of these children were previously described by Ingram and Bachynski with short-term follow-up. Classification and Methods of Treatment The sixty-one fractures were classified according to the four types described by Delbet and popularized by Colonna. Avulsion fractures of the greater and lesser trochanter and subtrochanteric fractures were excluded from this series. For this reason, we use the word intertroch anteric rather than peritrochanteric. 431

2 432 S. T. CANALE AND W. L. BOURLAND Most of the fractures were treated according to the methods described by Ingram and Bachynski. Their recommendations were: Type-I fractures with or without dislocation of the femoral head should have one attempt at closed reduction. If this is not successful, then immediate open reduction should be performed. in either case, pins should be used for internal fixation. Type- II and displaced Type-Ill fractures should be treated by gentle closed reduction and internal fixation with pins. Non-displaced Type-Ill and Type-lV fractures should be treated by the application of an abduction spica cast or traction spica cast. TABLE had complete dislocation of the femoral head from the acetabulum (Table II) and avascular necrosis developed in all of them no matter what treatment was given. Four had poor results and one, a fair result. The latter patient (Case 1) had avascula.r necrosis of the femoral head and premature epiphyseal closure. Her result, twenty-five years later, was considered fair because of some remodeling of the femoral head and lack of degenerative joint disease. However, it seems likely that, with age, degenerative arthritis also will develop. Three of the five children (Cases 2, 3, I RATLIFF s ASSESSMENT OF RESULTS Good Fair Poor Pain None or patient ignores it Occasional Disabling Movement Full or only terminal restriction Greater than 50 per cent Less than 50 per cent Activity Normal or patient avoids games Normal or patient avoids games Restricted Roentgenographic indications Normal or some deformity of femoral neck Severe deformity of femorai neck and Severe avascular necrosis, mild avascular necrosis degenerative arthritis, arthrodesis Results In evaluating the results, we assessed pain, motion, activity, and roentgenographic findings. To make possible an objective comparison with other groups of patients, Ratliff s assessment of results, which appears to be the most widely accepted, was used (Table I). In the entire series, at latest follow-up, there were thirty-five fractures with a good result, twelve with a fair result, and fourteen with a poor result. The results, classified according to the type of fracture, were as follows. Type I - Transepiphvseal Fractures All five of the patients with transepiphyseal fractures TABLE and 4) after six previous failed closed reductions were referred to the Campbell Clinic. An open reduction was performed in each case. In Case 3 a deep wound infection developed, with avascular necrosis and later a fibrous ankylosis ofthe hipjoint. In Cases 2 and 4 avascular necrosis developed, and at follow-up these patients had poor results with severe degenerative arthritis. In Case 5 closed reduction was successful but avascular necrosis developed. A cup arthroplasty was later performed. Type ii - Transcervical Fractures Of the twenty-seven transcervical fractures (Table Ill), twenty-two (Cases 6 through 27) were displaced at the time of initial treatment. Eighteen of these (Cases 6 II TRANSEPIPHYSEAL FRACTURES (TYPE I) Case* Age at Injury (Yrs.) Treatment Age at Last Followup (Yrs.) Avascular Necrosis Pmmature Closuret Pins across Plate Coxa Vara1 (Deg.) Non- Union Degenerative Arthritis Pain! Limited Motion Second Operation End Result Open red., 1 pin 2 3 Open red. 10 days postinjury (spica cast) 3 15 Open red. 60 days postinjury (spica cast), infected 4 14 Open red. 16 days postinjury cast) (spica 5 14 Closed red. (spica cast) 27 Yes* Yes Yes Epiphysiodesis Fair 34 Yes* Yes Yes Yes Epiphysiodesis Poor 33 Yes Yes Yes Yes Debrided twice; fibrous ankylosis 57 Yes Yes Yes Yes - Poor 49 Yesi N.E Yes - Cup arthroplasty Poor Total Poor * All Type-I fractures displaced with the epiphysis dislocated out of the acetabulum. t N.E. = not evaluated. 1: Neck-shaft angle less than 135 degrees. Treated with bed rest or non-weight-bearing for avascular necrosis. THE JOURNAL OF BONE AND JOINT SURGERY

3 FRACTURE OF THE NECK AND INTERTROCHANTERIC REGION OF THE FEMUR IN CHILDREN 433 through 23) were treated by gentle closed reduction and insertion of two or more parallel pins. The other four displaced fractures (Cases 24 through 27) were treated by closed reduction and application of an abduction spica cast. Of the twenty-two hips with displaced Type-lI fractures, fourteen had avascular necrosis (Figs. 1-A and 1-B); four, coxa vara (neck-shaft angles less than 135 degrees); two, non-union (Cases 8 and 9); and sixteen, premature closure of the capital femoral epiphysis. At follow-up, the result was good in eight patients, fair in seven, and poor in seven. However, four of the patients had secondary procedures about the hip, with improvement in the final result noted in two. Five transcervical fractures (Cases 28 through 32) were non-displaced. Three of these were treated with pins, one with an abduction spica cast, and one with bed rest. Avascular necrosis, non-union, and premature epiphyseal closure did not occur in these non-displaced fractures. There was one coxa vara (Case 28). At long-term follow-up, the results in all five fractures were considered good and no secondary procedures had been performed. Type III - Cervicotrochanteric Fractures Of twenty-two cervicotrochanteric fractures (Table IV), seventeen (Cases 33 through 49) were displaced at the time of initial treatment. Eleven of the seventeen fractures were treated with closed reduction and insertion of pins, and the rest were treated with various methods listed in Table I V. Of the seventeen patients with displaced fractures, six had avascular necrosis, while four had coxa vara and two, non-union. In eleven of these hips there was premature closure of the capital femoral epiphy- TABLE III TRANSCE RVICAL FRA CTURES (1 YPE II) Age at Last Pre- Pins Pain! Case Age at Injury (Yrs.) Treatment Displaced Followup (Yrs.) Avascular Necrosis mature Closure* across Plate Coxa Vara (Deg.) Degenerative Arthritis Limited Motion Second Operation End Result 6 12 Yes pins 27 Yes Yes Yes - - Yes - Poor 7 12 Yes pins 35 Yes Yes Yes - Yes Yes - Poor 8 15 Yes pins 38 Yes Yes Yes Blount valgus osteotomyt 9 15 Yes pins 36 Yes Yes Yes 126 Yes - Bone graft with valgus osteotomyt Fair Fair 10 8 Yes pins 12 Yesl Yes Yes Fair Il 12 Yes pins Yes Good Yes pins Yes Good Yes pins 28 - Yes Yes Good Yes Yes pins pins Yes Yes Yes N.E. No No - Yes - Fusion Poor Fair Yes pins 16 Yes Yes Yes - - Yes - Poor 17 6 Yes pins 40 Yes Yes Yes Epiphysiodesis and hip-flexor release 18 2 Yes pins No Good Yes pins 16 Yes Yes Yes Good 20 6 Yes pins No Good Yes pins 21 Yes Yes Yes - Yes Yes - Poor 22 3 Yes pins 13 - Yes Yes Good Yes pins 38 - Yes Yes - Yes Yes - Fair Fair Yes Closed reduction (spica cast) Yes Closed reduction (spica cast) Yes Closed reduction (spica cast) 27 Il Yes Closedreduction (spica cast) 31 Yes Yes Yes Epiphysiodesis Poor 51 Yes Yes Yes - - Fair 33 Yes Yes - 93 Yes - Osteotomy, then Poor fusion Good 28 6 No pins Yes Good No pins 19 - N.E. Yes Good 30 5 No pins 7 - N.E. Yes Good No Bed rest Good 32 4 No Traction,then spica cast Good Total * N.E. = not evaluated. i- For non-union. : Treated with bed rest or non-weight-bearing for avascular necrosis. VOL. 59-A, NO. 4, JUNE 1977

4 434 S. T. CANALE AND W. L. BOURLAND sis. At follow-up, eleven fractures had a good result (Figs. 2-A and 2-B); three, a fair result; and three, a poor resuit. Five of the seventeen hips had a secondary procedure, with improved results in two and worsened results in one. Five cerv icotroch anteric fractures (Cases 50 through 54) were non-displaced. Three were treated with abduction spica casts, one with bed rest, and one with pins. No avascular necrosis, coxa vara, non-union, or premature epiphyseal closure occurred in these patients. At followup, all five patients had a good result. Type 1 V - lntertrochanteric Fractures Seven patients had intertrochanteric fractures (Table V), four of which were initially displaced. Of the four displaced fractures, two were treated in abduction spica tient had avascular necrosis and premature epiphyseal dosure, with a poor result, but the other two patients had good results. There were no non-unions or other complications. A vascular Necrosis Complications In twenty-six patients (43 per cent), equally distributed as to sex, avascular necrosis developed following the original fracture and treatment. Three of the twenty-six patients were black, as compared with ten ofsixty patients in the whole series. The average age at injury for patients with avascular necrosis was 10.3 years (range, two to fifteen years): nineteen patients were more than ten years old. All of the five patients with Type-I fractures had avas- Type-Il displaced transcervical fracture of the right hip (Case 6) treated by closed reduction and fixation with pins. Nine months after fracture there is evidence of avascular necrosis. Anteroposterior roentgenograms show progression of avascular necrosis over a four-year period. casts and two by delayed internal fixation performed because of loss of position of the fragments (Figs. 3-A, 3-B, and 3-C). None of the four had avascular necrosis, but coxa vara developed in two and premature epiphyseal closure, in one. There were no non-unions. At long-term follow-up, three patients had good results while one had a fair result. One patient (Case 56) had a valgus osteotomy and a good final result. The three undisplaced intertrochanteric fractures were treated with abduction spici - #{231} or positioning. One pacular necrosis, compared with fourteen (52 per cent) with Type-Il, six (27 per cent) with Type-Ill, and one (14 per cent) with a Type-IV fracture. Twenty-five of the twenty-six fractures (92 per dent) that went on to avascular necrosis were displaced at the time of injury. Of the patients with displaced fractures (except Type I), seven were five years old or younger, and only one o1 them, aged five, had avascular necrosis (Case 36). Fifteen of the twenty-six patients with avascular necrosis had a closed reduction and -pin fixation, THE JOURNAL OF BONE AND JOINT SURGERY

5 FRACTURE OF THE NECK AND INTERTROCHANTERIC REGION OF THE FEMUR IN CHILDREN 435 FIG. 1-B Anteroposterior and lateral roentgenograms reveal severe degenerative changes secondary to avascular necrosis over a fourteen-year period follow. ing fracture. Fu;. 2-A Type-Ill displaced cervicotrochanteric fracture (Case 4) treated by closed reduction and -pin fixation. Anteroposterior and lateral roentgenograrns one year after fracture show mild residual varus deformity. but the type of primary treatment did not appear to corre- months following injury (range, 1.5 to eighteen months). late with the avascular process. Roentgenographic evi- Twenty-one patients had total involvement of the capital dence of avascular necrosis was noted an average of 9.3 femoral epiphysis (RatliffGrade I). One had involvement VOL. 59-A, NO. 4, JUNE 1977

6 436 S. T. CANALE AND W. L. BOURLAND Anteroposterior and lateral roentgenograms at twenty-three-year follow-up show good results and no evidence of residual coxa vara. ofonly the superior lateral portion ofthe femoral epiphysis At an average follow-up of 16.8 years, sixteen of the (Ratliff Grade 2). Four had sclerotic changes extending twenty-six patients had poor; nine, fair; and one, a good from the fracture line proximally as far as the epiphyseal result. Of the sixteen patients with poor results, twelve plate (Ratliff Grade 3). were more than ten years old at the time of fracture. Of the TABLE IV CERVICOTROCHANTERIC FRACTURES (TYPE III) Age at Last Pre- Pins Pain! Age at Dis- Follow- Avascular mature across Coxa Non- Degenerative Limited Second End Case Injury placed Treatment up Necrosis Closure* Plate Vara Union Arthritis Motion Operation Result (Yrs.) (Yrs.) (Deg.) Yes pins Yes Good Yes pins 31 - Yes Yes Good 35 3 Yes pins 10 - Yes No Good 36 5 Yes pins 8 Yes Yes Yes Yes - - Fair Yes pins 13 Yes - Yes - - Yes - Cup arthroplasty Poor Yes pins 23 Yes N.E. No - - Yes - Valgus osteotomy Fair Yes pins 20 - Yes Yes Good Yes pins 15 - Yes No Good 41 7 Yes pins 30 - Yes Yes Good 42 5 Yes pins No GOOd Yes Cast, then pins 38 Yes Yes Yes - - Yes Yes Bone graft Poor Yes Jewetinail 18 - Yes Good Yes pins, Jewett nail Yes pins, Jewett nail 19 Yes Yes Yes Good Yes Good 47 6 Yes Hip spica Good 48 7 Yes Skin traction, spica cast 16 - Yes - 80 Yes - Yes Valgus osteotomy Fair 49 6 Yes Bed rest 44 Yes Yes - 93 Yes Yes Yes Osteotomy with bone grafts: total hip replacement No Spica cast Good 51 3 No Spica cast Good 52 4 No Spica cast Good No pins Yes Good No Bed rest Go#{248}d Total Poor Good * N.E. = not evaluated. t Bilateral: see Case 57. : For non-union. Performed for severe pain secondary to degenerative changes. Severe concurrent injuries. THE JOURNAL OF BONE AND JOINT SURGERY

7 FRACTURE OF THE NECK AND INTERTROCHANTERIC REGION OF THE FEMUR IN CHILDREN 437 FIG. 3-B Figs. 3-A and 3-B: A displaced cervicotrochanteric (Type-Ill) fracture (Case 34), treated with closed reduction and pins. This patient also had a displaced intertrochanteric (Type-lV) fracture (Case 57) which, because of our persistent inability to maintain proper reduction with skeletal action, was treated by open reduction and internal fixation with a Jewett nail. FIG. 3-C Anteroposterior and lateral roentgenograms show the good result al seventeen-year follow-up. ten children with good or fair results, five were ten years old or younger at the time of fracture. The patients with Grades 1 and 2 avascular necrosis were noted to have a higher percentage of poor results. Of the twenty-six hips with avascular necrosis, twenty-two had necrosis without associated non-union or coxa vara and could be used to assess the results of treatment of the necrosis. Twelve hips had some form of treatment and ten had no treatment. For seven of the twelve hips specifically treated for avascular necrosis (Cases I, 2, 5, 10, 14, 15, and 19), bed rest or non-weight-bearing ambulation, started when the necrosis was first recognized and continued for an average of ninety-seven months, was the treatment employed. At final follow-up the results for these hips were good in one, fair in three, and poor in three. The four children with good and fair results remained non-weight-bearing for a minimum of one year. Ofthe other five hips specifically treated for avascular necrosis, one (Case 43) had a cortical-bone graft inserted into the avascular area with a poor result, one (Case 38) had a valgus osteotomy with a fair result, two (Cases 5 and VOL. 59-A, NO. 4, JUNE 1977

8 438 S. T. CANALE AND W. L. BOURLAND FIG. 4-A Roentgenograms of a transepiphyseal (Type-I) fracture and dislocation treated by delayed open reduction and -pin fixation (Case I ). At six weeks after surgery, there is evidence ofavascular necrosis. Serial roentgenograms made twenty-two months after fracture exhibit the progression of avascular necrosis with changes similar to those seen in the severe form of Perthes disease. 37) had cup arthroplasties with poor results, and one (Case 14) had hip fusion with a poor result. The ten hips that had no treatment for the avascular necrosis had the following results: six, poor; three, fair (Cases 15, 25, and 36): and one, good (Case 45). The hip with the good result was in a fourteen-year-old child with Grade-3 necrosis that involved the fracture site but not the epiphysis. The six children with poor results were eleven TABLE INTERTROCHANTERIC FRACTURES (TYPE IV) V Age at Dis- Case Injury placed (Yrs.) Treatment Age at last Followup (Yrs.) Avascular Necrosis Premature Closure* Pins across Plate Pain! Coxa Degenerative Limited Vara Arthritis Motion (Deg.) Second Operation End Result 55 6 Yes Traction, spica cast Good 56 5 Yes Spica cast 49 - N.E Valgus osteotomy Yes Delayed Jeweti nailing 31 - Yes - - Yes - Good 58 3 Yes Open red., internal I 12 - Yes - Fair fixation with Army - screws 59 #{189} No Positioning 17 Good 60 2#{189} No Spica cast Good No Spica cast 18 Yes Yes Yes Poor Total Good t Bilateral: see Case 34 (Table IV). * N.E. not evaluated. = THE JOURNAL OF BONE AND JOINT SURGERY

9 FRACTURE OF THE NECK AND INTERTROCHANTERIC REGION OF THE FEMUR IN CHILDREN 439 FIG. 4-B The patient was considered to have a fair result at twenty-five-year follow-up. years old or older at the time of injury. Of the twenty-six patients with avascular necrosis, eleven had roentgenographic evidence of repair or remodeling of the femoral head at latest follow-up, seven did not, and eight could not be evaluated, either because definitive secondary procedures had been done or because insufficient data were available. Four of the eleven patients with remodeling had Grade-3 and seven had Grade- 1 avascular necrosis. Five of the seven patients with more severe necrosis were ten years old or younger and two were eleven years old or older. Of the five younger patients, four had fair and one, a poor result. In three of these five patients there were roentgenographic changes indicative of remodeling. These resembled those seen in Legg- Calv#{233}-Perthes disease and progressed for an average of five years. If seen in a patient with Legg-Calv#{233}-Perthes disease, these changes would have been classified as Catterall Type I V, the so-called head at risk (Figs. 4-A and 4-B). The remaining two patients were older than ten years at injury and both had results considered fair at latest follow-up. One of these had had a previous valgus osteotomy and the other had been treated by non-we ightbearing for two years. The roentgenographic appearance in them did not so much resemble Perthes-like changes as the avascular necrosis seen following hip fractures in adults. The average time of remodeling in these two older patients was 9.3 years after injury. The seven patients with avascular necrosis and no evidence of remodeling had poor-to-fair results at latest follow-up. In five of the seven, it was an average of years before they began to complain of pain in the involved hip. Co.va Vara In thirteen children (2 1 per cent) coxa vara deformity developed soon after treatment. Seven of them had had reduction with internal fixation, and at their latest follow-up the coxa vara (average neck-shaft angle, 127 degrees) either had remained constant or had improved slightly. Three of the seven children obtained good results while four had fair results. Three had associated avascular necrosis. Five of the thirteen patients had been treated by application of abduction spica casts following initial reduction. The average deformity in this group was 94 degrees (Fig. 5). Some of the deformities were progressive, particularly in two of the five children (Cases 2 and 26) who had poor results associated with avascular necrosis. One patient (Case 25) had only a fair result because of secondary degenerative changes. Following correction of coxa vara and non-union by subtrochanteric osteotomy, one child (Case 8) had only a fair result because of persistent pain and limitation of joint motion. Another patient (Case 56) who had a subtrochanteric valgus osteotomy for coxa vara had a good result on forty-four-year follow-up even through the varus deformity was still present. One child (Case 49) was treated with bed rest only following fracture and had persistent varus deformity with VOL. 59-A, NO. 4, JUNE 1977

10 440 S. T. CANALE AND W. L. BOURLAND Severe coxa vara deformity (Case 56) following closed reduction and application of an abduction cast br a displaced intertrochanteric (Type-IV) fracture. The patient subsequently underwent a valgus subtrochanteric osteotomy. At forty-four-year follow-up the patient was considered It) have a good result. hut the coxa vara was still severe. degenerative changes following valgus osteotomy and bone graft. This patient subsequently had a good result following total hip replacement at the age of forty-four (Figs. 6-A and 6-B). Noti- Union Four children (Cases 8, 9, 48, and 49) had non-union after their primary treatment, giving an incidence of nonunion of 6.5 per cent. Two had displaced Type-Il and two, displaced Type-Ill fractures. Three of these children (Cases 9, 48, and 49) also had coxa vara; three (Cases 8, 9, and 49) had both avascular necrosis and premature dosure of the epiphyseal plate. All four non-unions were treated successfully by subtrochanteric valgus osteotomy. The coxa vara deformity was corrected in three of these four hips with fair results, while in the remaining hip (Case 49) the result was poor and total hip replacement was eventually performed. Premature Epiphvseal Closure For seven of the sixty-one hips (Cases 5, 15, 29, 30, 37, 38, and 56), the time ofclosure ofthe epiphyseal plate could not be determined either because of inadequate roentgenograms or because of early definitive secondary treatment. Of the remaining fifty-four hips, thirty-three showed premature closure, giving an incidence of premature dosure of 62 per cent. Considering all sixty-one fractures, there were thirty-six that were fixed with pins. In twentyeight of these thirty-six, the pins penetrated or completely traversed the epiphysis. Of these twenty-eight, five could not be evaluated for closure, eighteen closed prematurely, and five remained open. in the other eight hips in which the pins did not penetrate or traverse the epiphysis, the plate closed prematurely in four and remained open in four. Of the twenty-six hips with avascular necrosis, eighteen had premature closure and four did not, leaving four for which no data were available. In an effort to establish the relationship between limb-length discrepancy and premature closure of the capital femoral epiphysis, scanograms were obtained of the fifty-two patients in whom a comparison between their two lower limbs was possible. Of these fifty-two patients, twenty-six had significant shortening averaging 2. 1 centimeters (range, 0.5 to five centimeters) and twenty-six had no shortening. Of the twenty-six with shortening, twenty-three had premature closure of the epiphysis and three had avascular necrosis with early total collapse of the femoral head without closure of the plate. In twelve of these twenty-six patients with significant shortening the discrepancy was more than 2.0 centimeters. All twelve had had avascular necrosis as well as premature epiphyseal closure on the short side. Of the other fourteen patients whose discrepancy was less than two centimeters, six had had avascular necrosis as well as premature closure and eight had had premature closure without necrosis. Of the twenty-six patients who had no limb-length discrepancy, only six were known to have had premature epiphyseal closure. Four patients underwent epiphysiodesis of the opposite distal femoral epiphysis in an attempt to decrease limb-length discrepancy (Cases 1, 2, 17, and 24). Infection In one patient (Case 3) with a transepiphyseal dislocation a deep wound infection developed following open reduction two months after fracture-dislocation. On two occasions an incision and drainage procedure was performed. Severe avascular necrosis then developed. At latest follow-up, there was no drainage or evidence of infection but the result was poor because of painful fibrous ankylosis of this destroyed hip joint. Discussion The results in our patients were compared with those in the series of Ratliff and of Lam. In non-displaced fractures in all three series, there was a high percentage of good results no matter what treatment was followed. The THE JOURNAL OF BONE AND JOINT SURGERY

11 FRACTURE OF THE NECK AND INTERTROCHANTERIC REGION OF THE FEMUR IN CHILDREN 441 FIG. 6-A Severe coxa vara deformity (Case 49) following bed-rest treatment only. Seen at sixteen-year follow-up, the patient was asymptomatic. FIG. 6-B At thirty-eight-year follow-up, severe pain secondary to the coxa vara was noted, and a total hip replacement was done. results of displaced fractures in this series were similar to those in the patients described by Ratliff, but inferior to those reported by Lam (Table VI). Ratliff s suggested plan of treatment for displaced fractures of the femoral neck included primary subtrochanteric osteotomy for children under the age of ten. For those over ten years old, his recommendation was manipulative reduction and internal fixation. Contrary to this, Lam considered the displaced cervical fracture an unsolved problem, but recommended closed reduction for minimally displaced Type-Il and III fractures. Closed reduction was also his treatment of choice for displaced Type-Il and III fractures in the younger patients. In older patients with displaced Type-Il and III fractures, he recommended internal fixation. For this reason, his series contained more patients who had closed reduction and immobilization in spica casts. The numbers of patients with poor or fair results depended on the number of children with displaced fractures, and the ratios of displaced to non-displaced fractures varied considerably in the three series. Our percentage of avascular necrosis (43 per cent) was similar to that reported by Ratliff (42 per cent), but Lam reported only a 17 per cent incidence. The explanation for this difference is not clear. In our series, the factors that appeared to correlate with avascular necrosis were: a Type-I or II fracture; moderate or marked displacement of the fracture; and the age of the patient (over ten years). Lam had a smaller percentage of displaced fractures (53 per cent) when compared with our series (79 per cent) and that of Ratliff (64 per cent), but his incidence of avascular necrosis was so low that we cannot view displacement as the sole reason for the disparity between his results and those of Ratliff and ourselves. Because of the difference in results, we reanalyzed our series of Type-Il and displaced Type-Ill fractures. Of the twenty-seven Type-lI fractures, six were treated by VOL. 59-A, NO. 4, JUNE 1977

12 442 S. T. CANALE AND W. L. BOURLAND closed reduction and an abduction spica cast or bed rest, and twenty-one were treated by internal fixation. Considering the six treated without internal fixation, three of the four that were displaced had avascular necrosis, while neither of the two that were non-displaced showed evidence of necrosis. Of the twenty-one Type-Il fractures treated by -pin fixation, eighteen were displaced and eleven (61 per cent) of them showed avascular necrosis, while three were non-displaced and none of them had necrosis. Of the twenty-two Type-Ill fractures, seven were treated without and fifteen with internal fixation. Considering the seven treated without internal fixation, one of the three displaced fractures had avascular necrosis while none of the four non-displaced fractures had necrosis. Of the fifteen Type-Ill fractures treated by internal fixation, fourteen were displaced and five (36 per cent) of poorest in this series. All five patients had avascular necrosis and four of the five had poor results. These five patients injuries had two features in common: dislocation of the femoral head at the time of injury and multiple attempts at closed reduction. Both of these factors are likely to disrupt the circulation to the head of the femur and cause avascular necrosis. Therefore, if one attempt at closed reduction fails, open reduction and internal fixation is mdicated. While we had no experience with fractures in this group in which the head was not dislocated, it would appear that multiple attempts at closed reduction should be avoided and the treatment regimen as already noted should be followed. Concerning primary treatment, we routinely used three pins for fixation, but more recently we have noted that two pins in the younger child (less than seven years old) are adequate. We also used a spica cast for a TABLE VI COMPARISO N OF RESULTS Results of Displaced Premature Fractures Displaced Avascular Epiphyseal Study Good Fair Poor Fractures Necrosis Coxa Vara Non-Union Closure (Per cent) (Per cent) (Per cent) (Per cent) Ratliff (1962) /70 (64%) Lam(l971) (53cF) Present study (1976) /61 (79f) them had avascular necrosis, while the one non-displaced fracture that was internally fixed did not have avascular necrosi. Therefore, we strongly believe that the avascular necrosis we saw was directly related to initial displacement of the fracture fragments and to compromise of the blood supply at the time of fracture, and that the type of treatment (provided that only one gentle closed reduction is performed) does not affect the rate of avascular necrosis. Fewer than half of the femora in our series treated by closed reduction and fixation by pins showed avascular necrosis, including all fracture types so treated. The larger number of unsatisfactory results in our series may also be explained, in part, by our longer follow-up. The decreased percentage of non-unions and significant coxa vara deformities in this series as compared with the percentages reported by Lam and Ratliff may be a reflection of the greater proportion of our patients who had reduction and internal fixation of their fractures. We do not believe that subtrochanteric osteotomy is indicated as a primary procedure, as recommended by Ratliff. Furthermore, because the percentage of non-union was lower in this series than in Lam s or Ratliff s, we feel justified in recommending Ingram and Bachynski s original treatment plan of internal fixation with pins in Type-lI and displaced Type-ill fractures. As would be expected, the results in Type-I fractures with complete dislocation of the femoral head were the minimum of six weeks after reduction and fixation of the fracture. Some distraction of fracture fragments may be caused by the insertion of the pins, and, therefore, we tried to place the pins parallel to each other with all of the threads of the pins proximal to the fracture. This should allow some compression of the fracture gap to be obtainable, once the pins are in place. We tried, unsuccessfully, to show whether premature closure of the epiphyseal plate is more or less frequent in fractured hips with pins crossing the plate than in fractured hips with pins not crossing the plate or hips treated without internal fixation. While each of the three treatment groups had a significant percentage of patients with premature closure, the group treated with pins crossing the plate had the highest percentage. Therefore, for the last seven years we have made an effort to avoid having pins cross the epiphyseal plate unless the fracture is situated in a high transcervical or epiphyseal plane. Complications following femoral-neck fractures in children seemingly will occur regardless of the type of treatment. With respect to coxa vara, the number of patients having this deformity after initial treatment by internal fixation was nearly the same as the number treated by external immobilization. However, those treated by internal fixation had a milder form of coxa vara and had better results. The varus angles after internal fixation appeared to be those accepted at the time of fixation. in our cases, mild coxa vara deformity ap- THE JOURNAL OF BONE AND JOINT SURGERY

13 FRACTURE OF THE NECK AND INTERTROCHANTER1C REGiON OF THE FEMUR IN CHiLDREN 443 peared to be compatible with a good result if there was no avascular necrosis or non-union. While our experience with patients with severe coxa vara deformities who did not have secondary procedures is limited, it would appear that severe coxa vara is progressive and can cause late degenerative changes in the hip. All of the non-unions in our series were noted in displaced Type-Il and Type-Ill fractures. Union ultimately occurred in all cases following a secondary valgus subtrochanteric osteotomy. Following fracture, 62 per cent of our patients had premature closure of the capital femoral epiphysis, although not all had significant shortening of the extremity. Of the patients with more than two centimeters of shortening, all had not only premature closure of the epiphysis, but also avascular necrosis. A high percentage (78 per cent) of premature epiphyseal closures occurred following penetration of the epiphysis with pins. Most of the poor results in this series were noted in children in whom avascular necrosis developed. This complication was more prevalent in the older children in the series and occurred most frequently with displaced fractures. Grade-3 avascular necrosis appeared to involve only the neck of the femur. The roentgenographic characteristic of this type of avascular necrosis is an area of increased sclerosis just proximal to the fracture, extending to the capital femoral epiphysis. In several of our patients with this finding there was mild comminution of the fracture and in some the pins had crossed the sclerotic zone. While the sclerosis was unequivocal, we believe that what has been described as Grade-3 avascular necrosis actually is an increased resorption and sclerosis secondary to fracture healing in the femoral neck. Whether or not this is true, most of the children with this type of sclerotic change obtained a good result from treatment and the only residuum was a slightly widened femoral neck. Grade- 1 avascular necrosis with total head involvement was noted in a majority of the twenty-six patients who had avascular necrosis. The process was severe and most of the patients ultimately had poor results. The younger children had a higher percentage of better results, primarily because of the ability to repair or remodel the avascular bone. In the older children, the results were less encouraging. Only two of the eighteen older patients showed any evidence of remodeling a Grade-l avascular necrosis, and even then the remodeling process was prolonged. Fortunately we were able to compare the series of Ingram and Bachynski from this clinic with the present series. Of their original twenty-four patients, eighteen were seen in follow-up and are reported in the present series. The results in fourteen of them were the same in 1976 as in 1953, but in the other four patients the results were poorer, primarily because of deterioration of the hip joint in the form of degenerative joint disease secondary to avascular necrosis. This occurred in some cases insidiously over a period of many years. References 1. CATTERALL. A.: The Natural History of Perthes Disease. J. Bone and Joint Surg., 53-B: 37-53, Feb CHUNG, S. M. K.: Brief Note. Methods for Locating the Missing Patients in Long-Term Follow-up Studies. J. Bone and Joint Surg., 53-A: I448-l45l,Oct COLONNA, P. C.: Fracture of the Neck of the Femur in Children. Am. J. Surg., 6: , DELBET, PIERRE: Cited in Colonna. 5. INGRAM, A. J., and BACHYNSKI, BORDEN: Fractures ofthe Hip in Children. Treatment and Results. J. Bone and Joint Surg., 35-A: Oct LAM, S. F.: Fractures of the Neck of the Femur in Children. J. Bone and Joint Surg., 53-A: , Sept RATLIFF. A. H. C.: Fractures of the Neck of the Femur in Children. J. Bone and Joint Surg., 44-B: , Aug VOL. 59-A, NO. 4, JUNE 1977