Fractures of the upper femur (proximal femoral fractures) are serious injuries with many complications. They are classified by the Delbet–Colonna system.
Type 1—Transepiphyseal Fractures
These fractures are common in infancy. They are often associated with child abuse. Manage undisplaced fractures in a spica cast in the human position as with DDH management. Displaced fractures usually require reduction. Decompress the joint. Place two or three smooth parallel K wires across the physis. Avoid joint penetration. Bend over the ends outside the femoral metaphysis to prevent migration. Advise the family of the risks of AVN and growth problems.
Type 2—Transcervical Fractures
Manage undisplaced fractures in a spica cast. Displaced fractures should be reduced, decompressed, and internally fixed. Fix with two cannulated screws if enough proximal bone is available. Otherwise, fix with three smooth parallel K wires that traverse the growth plate. Supplement fixation with a spica cast. Plan 8 weeks of immobilization. Advise the family of the risk of AVN.
Type 3—Cervicotrochanteric Fractures
Manage as a type 2 injury. Decompress and fix with screws. Supplement with a spica cast unless fixation is very secure to avoid coxa vara. Advise family of risk of AVN.
Type 4—Intertrochanteric Fractures
Provide secure internal fixation to avoid residual varus deformity.
Pathologic fractures occur usually in neuromuscular disorders such as myelodysplasia or cerebral palsy. If stable, they may be managed by simple immobilization. Manage unstable fractures by intramedullary fixation. Leave the fixation in place to avoid refracture.
These fractures of the femoral neck are rare in children. These fractures often cause pain. Radiographs may show sclerosis of the inferior portion of the neck. Bone scans are diagnostic. Manage by limiting activity or possible immobilization in a single-hip fiberglass walking spica cast to ensure compliance.
Complications of femoral neck fractures are relatively frequent because of the vulnerable vascular of the femoral head.
Avascular necrosis This complication occurs in about one-third of hip fractures. This complication is due to the tenuous vascularity of the femoral head. The vascular supply may be interrupted at several levels, causing varied patterns of necrosis. Early capsular decompression appears to reduce the risk of AVN. Follow hips at risk every month or two with a hip rotation test. With loss of motion or guarding, suspect this complication.
Nonunion Nonunion is relatively uncommon but may occur if reduction are incomplete. Most heal with a valgus osteotomy and rigid fixation.
Growth disturbance This complication occurs when physeal damage occurs. It is common in type 1 injuries. It is probably not preventable.
Coxa vara This complication is usually preventable by providing internal fixation of unstable fractures.
Nerve injury This complication is more common than often recognized. Fortunately, most recover spontaneously in 3–6 months.