What is the management of a shear fracture of the hip in a 9-year-old child after a road traffic accident (RTA)?

Management of Shear Fracture of the Hip in a 9-Year-Old Child After RTA

A shear fracture of the hip in a 9-year-old child after road traffic accident requires urgent surgical treatment with open reduction and internal fixation, performed by an experienced orthopedic surgeon within 24 hours to minimize the risk of avascular necrosis of the femoral head. 1

Understanding Shear Fractures in Children

Shear fractures of the femoral head in children are high-energy injuries that almost always occur in association with hip dislocation, typically posterior dislocation with fracture of the inferior aspect of the femoral head 1. These are classified according to the Pipkin classification system, which guides treatment decisions based on fragment size, degree of dislocation, and patient age 1.

Critical time-sensitive consideration: The risk of avascular necrosis increases dramatically when reduction is delayed beyond 3 days after injury 1. In one series, all six cases of avascular necrosis occurred in patients whose femoral heads were reduced no sooner than three days post-accident 1.

Immediate Management Priorities

Initial Stabilization and Pain Control

• Immobilization of the affected limb immediately upon presentation 2
• Opioid analgesia administered cautiously, with pain scores documented at rest and on movement 2
• Intravenous fluid therapy to address hypovolemia 2
• Femoral nerve block or fascia iliaca block for superior pain control, which can be administered by appropriately trained emergency department staff 2
• Simple analgesics like paracetamol should be prescribed regularly unless contraindicated 2

Diagnostic Imaging

• Plain radiography with cross-table lateral view of the hip and anteroposterior view of the pelvis to confirm the diagnosis 3
• MRI or CT scanning if occult fracture components are suspected or to better delineate fragment size and displacement 3
• Image intensifier availability in the operating theater is essential for intraoperative guidance 2

Surgical Treatment Algorithm

Indications for Urgent Surgery (Within 24 Hours)

All shear fractures of the hip in children require surgical intervention 1, 4. Conservative treatment is contraindicated because:

• Risk of avascular necrosis increases with delayed reduction 1
• Femoral neck fractures have no/little value with conservative treatment 4
• Multiple injuries (common in RTA) favor surgical management 4

Surgical Approach Selection

The specific surgical technique depends on the Pipkin classification:

• Type 1 fractures (inferior femoral head fragment, hip joint stable after reduction): Consider fragment excision if small, or open reduction and internal fixation if large 1
• Type 2 fractures (superior femoral head fragment): Require open reduction and internal fixation due to weight-bearing surface involvement 1
• Type 3 fractures (Type 1 or 2 with femoral neck fracture): Require combined fixation of both components 1
• Type 4 fractures (Type 1 or 2 with acetabular fracture): Most complex, requiring fixation of all components; highest risk of avascular necrosis 1

Surgical Considerations Specific to Children

• Experienced surgeon is mandatory to minimize operative time, blood loss, and complications 2
• Surgery should be performed in a dedicated trauma theater with appropriate equipment including image intensifier and traction table 2
• Physeal injury assessment is critical, as growth plate involvement affects long-term outcomes 4
• Children have higher remodeling capacity than adults, but femoral neck and head fractures are exceptions where this advantage is minimal 4

Perioperative Management

Preoperative Optimization

• Prophylactic antibiotics against Staphylococcus aureus before surgery 3
• Thromboembolic prophylaxis, preferably with low-molecular-weight heparin 3
• Pre-operative assessment should identify any associated injuries from the RTA 2
• Maintain normothermia with theater temperature at 20-23°C 2

Anesthetic Considerations

• Either general anesthesia or neuraxial blockade can be used 2
• Regional anesthesia may reduce postoperative confusion, though evidence is limited 2
• Peripheral nerve blockade should be added for postoperative analgesia 2

Postoperative Care and Rehabilitation

Immediate Postoperative Period

• Supplemental oxygen for at least 24 hours postoperatively 2
• Regular paracetamol with carefully prescribed opioid analgesia as needed 2
• Early mobilization as tolerated, guided by the surgical fixation stability 2
• Monitor for complications including compartment syndrome, infection, and neurovascular compromise 5

Rehabilitation Protocol

• Early postfracture physical training and muscle strengthening 2
• Long-term balance training to prevent future falls 2
• Weight-bearing status determined by the orthopedic surgeon based on fracture pattern and fixation stability 2
• Most children can successfully return to normal activities, though older children (like this 9-year-old) have higher rates of residual problems than younger children 6

Critical Pitfalls to Avoid

1. Delayed reduction beyond 72 hours dramatically increases avascular necrosis risk 1
2. Inadequate pain control increases morbidity and delays mobilization 2
3. Missing associated injuries common in RTA, particularly acetabular or femoral neck fractures 1
4. Underestimating blood loss in pediatric patients, who have smaller circulating volumes 2
5. Failure to provide thromboembolic prophylaxis despite lower baseline risk in children 3

Long-Term Monitoring

• Serial radiographs to monitor for avascular necrosis development, which may not be apparent immediately 1
• Growth monitoring of the affected limb, as physeal injury can cause leg length discrepancy 4
• Functional assessment at 1 year, as residual problems are reported in approximately 16% of children after traffic injuries, with knee problems being most common in lower extremity injuries 6
• Older children (like this 9-year-old) tend to report residual problems more frequently than younger children 6