PDF herunterladen
OP-Journal 2018; 34(03): 315-327
DOI: 10.1055/a-0624-4213
Fachwissen
Georg Thieme Verlag KG Stuttgart · New York

Diagnostik und Therapie von Verletzungen am proximalen Femur und Beckenavulsionsverletzungen bei Kindern sowie der Epiphysiolysis capitis femoris

Kai Ziebarth
,
Nadine Kaiser
,
Thoralf Liebs
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
09. November 2018 (online)

Auch verfügbar auf
   Lizenzen und Reprints

Zusammenfassung

Obwohl es sich bei Avulsionsverletzungen des Beckens, Frakturen des proximalen Femurs und der Epiphyseolysis capitis femoris um relativ seltene Krankheitsbilder handelt, ist eine korrekte Diagnostik und Therapie essentiell um langfristige Beschwerden und Einschränkungen zu verhindern. Eine Kenntnis der kindlichen Anatomie ist Voraussetzung für eine erfolgreiche Behandlung. Frakturen am proximalen Femur müssen größtenteils operiert und anatomisch reponiert werden, da wenig Remodellierungspotenzial besteht. Schenkelhalsfrakturen müssen kontrolliert reponiert werden, um die Gefäßversorgung des Femurkopfes nicht zu gefährden. Es empfiehlt sich somit eine offene Reposition. Avulsionsverletzungen müssen bei Sportverletzungen beim Kind aktiv gesucht werden und können klinisch angesichts der starken Schmerzangaben häufig dramatisch erscheinen. Die Domäne der Avulsionsverletzung ist die konservative Therapie. Ein Kind zwischen 10 und 16 Jahren mit Knieschmerzen und eingeschränkter Hüftrotation oder hinkendem Gangbild muss zum Ausschluss einer ECF radiologisch abgeklärt werden. Das positive Drehmann-Zeichen ist klinisch pathognomonisch für eine ECF. Klinische Klassifikationen können die Stabilität der Wachstumsfuge nicht genau vorhersagen, daher ist nach Diagnosestellung eine Stockentlastung bis zur operativen Versorgung empfehlenswert. Die Behandlung der ECF besteht immer in der operativen Stabilisation des Femurkopfes mit Schrauben oder Drähten und, je nachdem, in der anatomischen Wiederherstellung der proximalen femoralen Anatomie.

Abstract

Injuries of the proximal aspect of the femur in children are much less frequent than injuries of the upper extremities. Knowledge and respect of the anatomy is the key to sufficient therapy and good patient outcomes. Most fractures of the proximal aspect of the femur need open reduction and internal fixation, since there is insufficient potential for remodelling. Fractures of the femoral neck need an open reduction so that the perfusion of the femoral head is not put at risk. In sports injuries, avulsion fractures have to be searched for. Children suffering from these fractures can present with surprisingly high levels of pain. Most avulsion fractures are treated conservatively. In a child aged 10 – 16 years presenting with knee pain, who is limping or who has a decreased range of motion of the hip, a slipped capital femoral epiphysis (SCFE) must be ruled out radiographically. The Drehmann sign is pathognomonic for a SCFE. Current clinical classifications are not able to predict the stability of the physis. Therefore, non-weight-bearing is mandatory in the interval between diagnosis and operative treatment. Treatment of SCFE always includes an operative stabilization of the femoral head using transphyseal screws or wires. Contemporary treatment includes a reconstruction of the proximal femoral anatomy in displaced cases.

Schlüsselwörter

Hüftschmerz - Epiphysiolysis capitis femoris - proximale Femurfraktur - Avulsion - Hüfte

Key words

hip pain - slipped capital femoral epiphysis - proximal femoral fracture - avulsion - hip
 

  • Literatur

  • 1 Beaty JH, Kasser JR. eds., Rockwood and Wilkinsʼ Fractures in Children. Philadelphia: Lippincott Williams & Wilkins; 2010
    Google Scholar
  • 2 Johnson EO, Soultanis K, Soucacos PN. Vascular anatomy and microcirculation of skeletal zones vulnerable to osteonecrosis: vascularization of the femoral head. Orthop Clin North Am 2004; 35: 285-291 viii
    CrossrefPubMedGoogle Scholar
  • 3 Slongo T, Audigé L, Schlickewei W. et al. Development and validation of the AO pediatric comprehensive classification of long bone fractures by the Pediatric Expert Group of the AO Foundation in collaboration with AO Clinical Investigation and Documentation and the International Association for Pediatric Traumatology. J Pediatr Orthop 2006; 26: 43-49
    CrossrefPubMedGoogle Scholar
  • 4 Arbeitsgemeinschaft für Osteosynthesefragen. Howard A, Hunter J, Slongo T. et al. Im Internet: https://www2.aofoundation.org/wps/portal/surgery Stand: 01.07.2018
    PubMed
  • 5 Yeranosian M, Horneff JG, Baldwin K. et al. Factors affecting the outcome of fractures of the femoral neck in children and adolescents: a systematic review. Bone Joint J 2013; 95-B: 135-142
    CrossrefPubMedGoogle Scholar
  • 6 Dial BL, Lark RK. Pediatric proximal femur fractures. J Orthop 2018; 15: 529-535
    CrossrefPubMedGoogle Scholar
  • 7 Schuett DJ, Bomar JD, Pennock AT. Pelvic apophyseal avulsion fractures: a retrospective review of 228 cases. J Pediatr Orthop 2015; 35: 617-623
    CrossrefPubMedGoogle Scholar
  • 8 McKinney BI, Nelson C, Carrion W. Apophyseal avulsion fractures of the hip and pelvis. Orthopedics 2009; 32: 42
    CrossrefPubMedGoogle Scholar
  • 9 Metzmaker JN, Pappas AM. Avulsion fractures of the pelvis. Am J Sports Med 1985; 13: 349-358
    CrossrefPubMedGoogle Scholar
  • 10 Gidwani S, Jagiello J, Bircher M. Avulsion fracture of the ischial tuberosity in adolescents–an easily missed diagnosis. BMJ 2004; 329: 99-100
    CrossrefPubMedGoogle Scholar
  • 11 Ferlic PW, Sadoghi P, Singer G. et al. Treatment for ischial tuberosity avulsion fractures in adolescent athletes. Knee Surg Sports Traumatol Arthrosc 2014; 22: 893-897
    CrossrefPubMedGoogle Scholar
  • 12 Aronsson DD, Loder RT, Breur GJ. et al. Slipped capital femoral epiphysis: current concepts. J Am Acad Orthop Surg 2006; 14: 666-679
    CrossrefPubMedGoogle Scholar
  • 13 Zupanc O, Kizancic M, Daniel M. et al. Shear stress in epiphyseal growth plate is a risk factor for slipped capital femoral epiphysis. J Pediatr Orthop 2008; 28: 444-451
    CrossrefPubMedGoogle Scholar
  • 14 Loder RT. The demographics of slipped capital femoral epiphysis. An international multicenter study. Clin Orthop Relat Res 1996; (322) 8-27
    PubMedGoogle Scholar
  • 15 Loder RT, Skopelja EN. The epidemiology and demographics of slipped capital femoral epiphysis. ISRN Orthop 2011; 2011: 486512
    PubMedGoogle Scholar
  • 16 Witbreuk MM, van Royen BJ, Van Kemenade FJ. et al. Incidence and gender differences of slipped capital femoral epiphysis in the Netherlands from 1998–2010 combined with a review of the literature on the epidemiology of SCFE. J Child Orthop 2013; 7: 99-105
    CrossrefPubMedGoogle Scholar
  • 17 Jerre R, Billing L, Hansson G. et al. Bilaterality in slipped capital femoral epiphysis: importance of a reliable radiographic method. J Pediatr Orthop B 1996; 5: 80-84
    CrossrefPubMedGoogle Scholar
  • 18 Jerre R, Billing L, Hansson G. et al. The contralateral hip in patients primarily treated for unilateral slipped upper femoral epiphysis. Long-term follow-up of 61 hips. J Bone Joint Surg Br 1994; 76: 563-567
    PubMedGoogle Scholar
  • 19 Fahey JJ, OʼBrien ET. Acute slipped capital femoral epiphysis: review of the literature and report of ten cases. J Bone Joint Surg Am 1965; 47: 1105-1127
    CrossrefPubMedGoogle Scholar
  • 20 Loder RT, Richards BS, Shapiro PS. et al. Acute slipped capital femoral epiphysis: the importance of physeal stability. J Bone Joint Surg Am 1993; 75: 1134-1140
    CrossrefPubMedGoogle Scholar
  • 21 Ziebarth K, Domayer S, Slongo T. et al. Clinical stability of slipped capital femoral epiphysis does not correlate with intraoperative stability. Clin Orthop Relat Res 2012; 470: 2274-2279
    CrossrefPubMedGoogle Scholar
  • 22 Carney BT, Weinstein SL. Natural history of untreated chronic slipped capital femoral epiphysis. Clin Orthop Relat Res 1996; (322) 43-47
    PubMedGoogle Scholar
  • 23 Dobbs MB, Weinstein SL. Natural history and long-term outcomes of slipped capital femoral epiphysis. Instr Course Lect 2001; 50: 571-575
    PubMedGoogle Scholar
  • 24 Weinstein SL. Natural history and treatment outcomes of childhood hip disorders. Clin Orthop Relat Res 1997; (344) 227-242
    PubMedGoogle Scholar
  • 25 Dunn DM. The treatment of adolescent slipping of the upper femoral epiphysis. J Bone Joint Surg Br 1964; 46: 621-629
    PubMedGoogle Scholar
  • 26 Dunn DM, Angel JC. Replacement of the femoral head by open operation in severe adolescent slipping of the upper femoral epiphysis. J Bone Joint Surg Br 1978; 60-B: 394-403
    CrossrefPubMedGoogle Scholar
  • 27 Leunig M, Casillas MM, Hamlet M. et al. Slipped capital femoral epiphysis: early mechanical damage to the acetabular cartilage by a prominent femoral metaphysis. Acta Orthop Scand 2000; 71: 370-375
    CrossrefPubMedGoogle Scholar
  • 28 Leunig M, Fraitzl CR, Ganz R. [Early damage to the acetabular cartilage in slipped capital femoral epiphysis. Therapeutic consequences]. Orthopade 2002; 31: 894-899
    CrossrefPubMedGoogle Scholar
  • 29 Ziebarth K, Leunig M, Slongo T. et al. Slipped capital femoral epiphysis: relevant pathophysiological findings with open surgery. Clin Orthop Relat Res 2013; 471: 2156-2162
    CrossrefPubMedGoogle Scholar
  • 30 Larson AN, Sierra RJ, Yu EM. et al. Outcomes of slipped capital femoral epiphysis treated with in situ pinning. J Pediatr Orthop 2012; 32: 125-130
    CrossrefPubMedGoogle Scholar
  • 31 Ganz R, Gill TJ, Gautier E. et al. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001; 83: 1119-1124
    CrossrefPubMedGoogle Scholar
  • 32 Leunig M, Slongo T, Ganz R. Subcapital realignment in slipped capital femoral epiphysis: surgical hip dislocation and trimming of the stable trochanter to protect the perfusion of the epiphysis. Instr Course Lect 2008; 57: 499-507
    PubMedGoogle Scholar
  • 33 Leunig M, Slong T, Kleinschmidt M. et al. Subcapital correction osteotomy in slipped capital femoral epiphysis by means of surgical hip dislocation. Oper Orthop Traumatol 2007; 19: 389-410
    CrossrefPubMedGoogle Scholar
  • 34 Slongo T, Kakaty D, Krause F. et al. Treatment of slipped capital femoral epiphysis with a modified Dunn procedure. J Bone Joint Surg Am 2010; 92: 2898-2908
    CrossrefPubMedGoogle Scholar
  • 35 Ziebarth K, Zilkens C, Spencer S. et al. Capital realignment for moderate and severe SCFE using a modified Dunn procedure. Clin Orthop Relat Res 2009; 467: 704-716
    CrossrefPubMedGoogle Scholar
  • 36 Huber H, Dora C, Ramseier LE. et al. Adolescent slipped capital femoral epiphysis treated by a modified Dunn osteotomy with surgical hip dislocation. J Bone Joint Surg Br 2011; 93: 833-838
    PubMedGoogle Scholar
  • 37 Kennedy JG, Hresko MT, Kasser JR. et al. Osteonecrosis of the femoral head associated with slipped capital femoral epiphysis. J Pediatr Orthop 2001; 21: 189-193
    PubMedGoogle Scholar
  • 38 Tokmakova KP, Stanton RP, Mason DE. Factors influencing the development of osteonecrosis in patients treated for slipped capital femoral epiphysis. J Bone Joint Surg Am 2003; 85-A: 798-801
    PubMedGoogle Scholar
  • 39 Ziebarth K, Milosevic M, Lerch TD. et al. High survivorship and little osteoarthritis at 10-year followup in SCFE patients treated with a modified Dunn procedure. Clin Orthop Relat Res 2017; 475: 1212-1228
    CrossrefPubMedGoogle Scholar