Management of Neglected Acetabulum Fracture in a 1-Year-Old
Immediate referral to a pediatric orthopedic surgeon is mandatory for this complex fracture requiring specialized expertise. 1
Immediate Referral Criteria
The American Academy of Pediatrics explicitly recommends that infants, children, and adolescents with multiple skeletal trauma or complex fractures and dislocations should be managed by a pediatric orthopedic surgeon who has completed fellowship training in pediatric orthopedics. 1 A neglected acetabulum fracture in an infant falls squarely into this category given the complexity of pelvic fractures and the critical developmental implications at this age.
Initial Assessment by the Specialist
The pediatric orthopedic surgeon should obtain:
- CT scan with 3D reconstruction to comprehensively evaluate the fracture pattern, bone integrity, displacement, and any associated injuries 2, 3
- Assessment of hip stability and whether the femoral head remains congruent with the acetabulum 3, 4
- Evaluation for femoral head damage, avascular necrosis risk, and callus formation that may complicate reduction 4
- Determination of fracture union status (non-united versus malunited), as malunited fractures are significantly more difficult to manage 3
Treatment Decision Algorithm
For Non-United Fractures with Preserved Femoral Head:
Attempt open reduction and internal fixation (ORIF) to restore anatomical alignment. 3, 4 Even in neglected cases, ORIF should be attempted when possible to restore the anatomical relationship of the acetabulum. 3 This is particularly important in a 1-year-old where:
- The remodeling potential is substantial 1
- Preserving the native hip joint is critical for growth and development
- Anatomical reduction provides the best long-term outcome 5
For Malunited Fractures or Those with Femoral Head Damage:
The situation becomes more complex. 3, 4 In adults, total hip arthroplasty would be considered, but this is not an option in a 1-year-old infant. 4, 6 The specialist must:
- Attempt ORIF with bone grafting if reduction is feasible 4
- Accept that outcomes may be suboptimal given the neglect period 3
- Plan for staged reconstructive procedures as the child grows
Critical Prognostic Factors
The degree of congruence between the acetabulum and femoral head is the single most important determinant of outcome. 5 Total incongruence (where fragments remain separated from the femoral head on all radiographic views) mandates operative treatment. 5
The neglect period significantly impacts outcomes. 3 Callus formation makes fragment mobilization difficult, and prolonged abnormal contact damages the femoral head cartilage. 4
Special Pediatric Considerations
- Avascular necrosis of the femoral head is the most feared complication in pediatric hip trauma 7
- Surgical approaches must minimize additional vascular insult 7
- Hip arthroscopy may have a role in selected cases to reduce surgical morbidity 7
- The high remodeling potential in infants may allow acceptance of some residual deformity that would be unacceptable in adults 1
Common Pitfalls to Avoid
- Do not delay referral - this is already a neglected fracture; further delay worsens prognosis 3, 4
- Do not attempt management without pediatric orthopedic expertise - these are among the most complex pediatric fractures 1
- Do not assume conservative management is safer - total incongruence requires operative intervention 5
- Do not use cemented acetabular components if arthroplasty becomes necessary later - these have high failure rates in post-traumatic settings 6