Patient: 13-year-old boy Presentation: Fall from bicycle at high speed 3 hours ago, unable to weight-bear, right hip pain Relevant history: High-energy mechanism, no head injury, no other injuries identified, previously healthy, no bone disease, no medications Examination findings:
| Test | Result | Normal Range | Interpretation |
|---|---|---|---|
| Hb | 115 g/L | 120-150 g/L | ↓ Mild decrease (blood loss) |
| WCC | 12.5 ×10⁹/L | 5-15 ×10⁹/L | Upper normal (stress response) |
| Platelets | 310 ×10⁹/L | 150-400 ×10⁹/L | Normal |
| Group & Screen | O positive | - | Available for transfusion |
| Coagulation | Normal | - | Normal |
Image 1: AP Pelvis and Lateral Hip Radiograph
Radiological features:
Classification: Delbet Type II (Transcervical) - displaced
What is the diagnosis and classification, and why is this injury significant?
What is your immediate management plan?
Describe your surgical technique.
What are the complications and how would you monitor for AVN?
The fracture heals but develops coxa vara. How would you manage this?
How do you counsel the parents about prognosis and long-term follow-up?
This pattern suggests Paediatric Femoral Neck Fracture:
Distinguish from SUFE:
| Feature | Femoral Neck Fracture | SUFE |
|---|---|---|
| Mechanism | High-energy trauma | Low/no trauma |
| Onset | Acute | Often insidious |
| Habitus | Any | Often obese |
| X-ray | Visible fracture line | Physeal widening, metaphyseal blanch |
| Treatment | Urgent ORIF | Urgent in situ pinning |
Q: "Why is capsulotomy important?"
The femoral head in children has a tenuous blood supply:
Studies show lower AVN rates with capsulotomy, though evidence is limited by small numbers. It is considered standard of care in paediatric femoral neck fractures.
Q: "How do you fix across an open physis?"
Options for fixation crossing the physis:
Accept some physeal damage for stable fixation - the priority is fracture healing and AVN prevention. Premature physeal closure is a lesser problem than AVN or nonunion.
Q: "This child develops AVN at 6 months. What are your options?"
Management depends on severity and age:
Mild AVN (Ficat I-II, no collapse):
Moderate AVN (early collapse):
Severe AVN (significant collapse):
Key Point: Young children have some remodelling potential. Severe AVN in an adolescent has poor prognosis.
Q: "What is the Ratliff classification?"
Ratliff classification is an outcome classification based on final result:
| Type | Outcome |
|---|---|
| I | Good - normal or near-normal hip |
| II | Fair - some abnormality but functional |
| III | Poor - significant disability, AVN, or need for salvage surgery |
It is used to report outcomes in studies but doesn't guide treatment.