11 / 99
A
kkari
M
et
al
.
6
R
ev
A
ssoc
M
ed
B
ras
2015; 61(1):5-7
life, i.e. older children have higher risk compared to youn-
ger children (
A
).
3
With regard to deviation, we found no
quantification of the risk, but there is a directly proportio-
nal relationship of AVN in patients with larger deviations
(
B
).
4
Also, in terms of quality of reduction, anatomical re-
ductions are related to lower rates of AVN(
B
).
4
Recommendation
There is no way to predict with certainty which patients
will develop AVN; however, age, type of fracture, degree
of deviation and quality of reduction were the factors
most correlated. Therefore, these variables must be con-
sidered in treatment planning and patient follow-up.
S
urgical
or
conservative
treatment
?
Several treatment methods are described in the literature,
from non-surgical treatments including closed reduction
and immobilization in a cast, to cases of open reduction
with internal fixation and osteotomies. This reflects a huge
concern to avoid late
sequelae
of a poorly planned treat-
ment. It is known that both quality of reduction and sta-
bilization of fractures are essential to a successful outco-
me. It is recommended to perform early treatment within
24 hours of the trauma event, and internal fixation with
Kirschner wires or screws (
B
).
5-7
Using Ratliff (
C
)
8
evalua-
tion criteria, which are based on clinical and radiological
data after treatment, better results may be seen in patients
undergoing internal fixation, regardless of the type of os-
teosynthesis used (
B
).
5-7,9
In a retrospective study, 69.3% of
the results were good in surgically treated patients, com-
pared with 17% for patients treated in a closed manner (
B
).
9
Recommendation
Studies show that surgical treatment with fracture fixa-
tion produces better results, and thus this is the recom-
mended treatment.
W
hat
kind
of
reduction
(
open
or
closed
)
is most
appropriate
in
this
type
of
fracture
?
Many methods of treatment for proximal femoral frac-
tures in children have been described; however, some have
become obsolete over the years. With increased unders-
tanding of these injuries and studies performed on frac-
ture management, the aim is currently that of treatment
with anatomical reduction and focus stability. Closed
treatment has become the exception. Based on other stu-
dies, one can prove the benefit of anatomical reductions
to prevent complications. Some factors may determine
the approach to be used (open or closed). Difficulty in
achieving closed reduction may determine a change to
open reduction. The important thing in this situation is
not to damage the vascularization even more with unti-
mely and fruitless maneuvers. Another important point
is the availability of suitable materials such as radioscopy,
which facilitate reduction and fixation without opening
the fracture focus. Recent studies show better results
with an open approach, but we must consider that these
procedures usually lead to anatomical reduction
(
B
).
10,11
Recommendation
Open reduction should always be considered when it is
difficult to achieve a satisfactory closed reduction.
D
oes
early
hip
decompression
reduce
the
risk
of
avascular
necrosis
?
The blood supply to the head and neck of the femur in
children, unlike adults, receives little contribution from
the round ligament artery. The main source of blood supply
is through lateral epiphyseal vessels and upper and lower
metaphyseal vessels, all branches of the medial circumflex
artery. A deviated fracture can cut the intra bone vascular
supply, and produce a synovial rupture by severing the me-
taphyseal and epiphyseal lateral branches. This initial da-
mage is not correctable since it occurred in the event of
trauma (
C
).
2
Once the fracture occurs, it is possible, howe-
ver, to reduce the risk of premature AVN through early de-
compression of hemarthrosis (24-36 hours after trauma)
done by joint aspiration (
B
).
12
Hemarthrosis also contri-
butes to the genesis of AVN, as it buffers the vessels, con-
tributing to necrosis, which is evidenced by some authors
as a lower rate of AVN after decompression (
B
).
5,7,13,14
Recommendation
Based on evidence that the decompression of the articu-
lar hematoma leads to lower rates of AVN, it should be
performed as soon as possible.
W
hat
is
the maximum
time
between
the
accident
and
early
therapeutic
approach
to minimize
the most
common
complications
?
Femoral neck fractures in children are serious and also
associated with high rates of complications. Since the be-
ginning of treatment, we must act to prevent early and
late complications. Therefore, anatomical reduction and
internal fixation performed on an urgent basis have been
recommended for therapeutic success (
B
).
9
Some studies
have shown higher rates of good results in patients trea-
ted within the first 24 hours after trauma (
B
).
9,15-18