Avascular Necrosis of the Femoral Head after Displaced Fractures of the Femoral Neck in Children

小兒股骨頸移位性骨折併發股骨頭缺血性壞死

陳識仁(Shih-Jen Chen) ； 胡仲行(Chung-Hsing Hu) ； 陳新耀(Hsin-Yao Chen) ； 潘文惇(Man-Dun Poon) ； 林惠民(Huei-Ming Lin) ； 于振東(Chen-Tung Yu) ； 張櫻霖(Ing-Lin Chang) ； 黃慧珍(Huei-Jen Huang)

《The Changhua Journal of Medicine》 8卷4期 (2003/10) Pp. 217-224

摘要

背景及目的：小兒股骨頸移位性骨折很少見，通常是嚴重創傷造成的，且會合併其它地方的損傷。另外，此骨折結果常伴隨著麻煩的併發症，如股骨頭缺血性壞死、生長板提早關閉而造成下肢長短不等，癒合不良等等。本文章主要提供本院的經驗以探討併發症產生之原因及安全的治療方法。
方法：我們自1990年到2000年共收集十七例，皆屬移位性骨折，受傷年齡平均11.5歲，並以徒手性或開放性復位加上鋼釘固定治療，或石膏輔助固定。術後追蹤至少兩年以上，並紀錄骨折的分類(Delbet's classification)、癒合狀況、缺血性壞死的產生及原因、和其它併發症，且以Ratllif建議的標準來評估臨床結果。
結果：術後平均追蹤6.5年；十三例臨床結果屬好；五例產生缺血性壞死，其中四例臨床結果屬差，另一例雖有缺血性壞死，但最後臨床結果屬好，因為此病人並無股骨頭塌陷，而只有生長板提早關閉造成患肢短1.5公分，功能上並無障礙。我們發現第一類型骨折的病人有兩例，全產生股骨頭缺血性壞死；另外臨床結果屬差的病人中，有三人的年齡大於十二歲。合併產生它處損傷的個案有八例。延遲復位者有七例，其中三例產生缺血性壞死。
結論：對於此類骨折：須先仔細檢查有無合併其它處受傷；盡量能在二十四小時內手術復位及固定；Delbet's type I骨折，預後極差；產生Ratiff type I股骨頭缺血性壞死者，預後最差；生長板提早關閉而產生股骨頸短小變形者，預後不差；受傷時的年齡大於十二歲者且合併缺血性壞死者，預後較差。

關鍵字

小兒股骨頸移位性骨折 ； 股骨頭缺血性壞死 ； 生長板提早關閉

並列摘要

Background and purpose: Displaced fracture of the femoral neck is uncommon in children, and is usually secondary to significant trauma or another injury. Numerous serious complications, such as avascular necrosis (AVN) of the femoral head, nonunion, and premature physeal arrest, can result from this fracture. We investigated the predisposing factors for the complications and report our experiences with surgical repair.
Methods: Between January 1990 and December 2000, we treated 17 patients with displaced fracture of the femoral neck (mean age, 11.5 years; range, 5 to 14). A closed reduction and internal fixation was performed under fluoroscopic guidance within 24 hours postinjury if possible. If an anatomic reduction was not achieved, an open procedure was considered. External immobilization with a spica cast was used if the fixation was not secure. All patients were followed for 2 years. We classified the fracture pattern according to Delbet's method and utilized the Ratliff's criteria to evaluate clinical results. Patterns of AVN, as described by Ratliff were also recorded.
Results: Thirteen hips were graded as having good clinical outcome and 4 as having poor clinical outcome: Type I AVN occurred in 4 hips which required arthroplasty later. Only 1 patient developed type III AVN, which was associated with premature physeal closure. According to Delbet's classification, there were 2 type-I, 12 type-II, and 3 type-III fractures. All the type-I fractures developed AVN. Of the 4 patients with poor outcome, 3 were older than 12. Eight fractures were associated with other serious injuries. Of the 7 fractures with delayed reduction, 3 developed AVN. Mean follow-up was 6.5 years (range, 2 to 10).
Conclusions: Age of the child, the type of hip fracture, the amount of fracture displacement, and the severity of concomitant trauma are prognostic factors. Although no definite relationship with the poor outcome has been established, the delayed reduction should be avoided if possible. If the security of internal fixation is not adequate, external immobilization is recommended. Type I AVN always resulted in late sequelae. Premature physeal closure alone was not responsible for a poor result. In older children with AVN, the results are less encouraging.

並列關鍵字

displaced femoral neck fractures in children ； avascular necrosis ； premature physeal closure