Arch Orthop Trauma Surg (2004) 124 : 69–71 DOI 10.1007/s00402-003-0600-2
C A S E R E P O RT
Jan Bartoníček · Petr Havránek
Gunshot injury of the proximal femoral physis
Received: 15 April 2003 / Published online: 21 November 2003 © Springer-Verlag 2003
Abstract A 12-year-old boy sustained a gunshot injury to the proximal femur. The bullet hole passed through the femoral neck very close to the proximal femoral physis (Ogden type 8 physeal injury) without neurovascular injury. The boy was treated conservatively with antibiotics and bedrest. Nine months later, avascular necrosis of the femoral head (Ratliff type 2) and limb shortening of 2 cm had developed. For this reason, a valgus intertrochanteric osteotomy was performed 1 year after the injury. However, only partial revascularization of a necrotic femoral head segment occurred. For the residual necrotic segment in the weight-bearing area and progressive shortening of the femur 3.5 years after injury, a valgus-extension intertrochanteric osteotomy was performed and remodelling of the necrotic fragment done. The boy is now over 19 years old. He has only minimal pain after sports activity and a slightly limited range of movement. The limb shortening is 1.5 cm.
Case report A 12-year-old boy was shot in the left hip by his classmate who was playing with his father’s gun. The shot passed just under the inguinal ligament and exited dorsally from the gluteal region. Plain X-rays as well as CT scans showed a bullet hole through the femoral neck metaphysis very close to the physis (Figs. 1, 2a). No blood vessel or nerve injury (femoral vessels or ischiadic nerve) had occurred. The boy was treated only with bedrest and antibiotics. The soft-tissue wounds healed without sequelae. However, over 9 months a progressive femoral head necrosis Ratliff type 2 with premature growth cessation and 2-cm limb shortening developed (Figs. 2b,c, 3a) [5]. Therefore, after MRI examination a 40 deg valgus intertrochanteric osteotomy fixed by a 120-deg, double-angled blade
Keywords Proximal femoral fractures · Gunshot injuries · Fractures in children · Physeal injuries · Growth impairment
Introduction A proximal physeal femoral injury in children is extremely rare. Usually, traumatic separation of the epiphysis is reported in unique cases or in a small patient cohort. We have not found any references to gunshot injury as a mechanism of physeal trauma with subsequent influence on the femoral head epiphysis [1, 2, 3, 4, 7, 8].
J. Bartoníček (✉) · P. Havránek Orthopaedic Department of 3rd Faculty of Medicine, Charles University, Šrobárova 50, 100 34 Prague 10, Czech Republic Tel.: +420-2-67162716, Fax: +420-2-67313372, e-mail:
[email protected]
Fig. 1a–c CT scan showing a bullet hole through the proximal femoral metaphysis very close to the physis
70 Fig. 2 a Injury X-ray of the left hip with a visible bullet hole in the femoral neck. b Progression of the area of the metaphyseal bone necrosis 1 month after the injury. c In 3 months, the whole metaphysis proximal of the physis is affected by necrosis
Fig. 3 a Nine months after the injury, a collapse of the femoral head with a large necrotic fragment is evident. Only the medial portion of the head is intact. b One year after the injury, a valgus intertrochanteric osteotomy is performed. The blade of the plate is inserted through the greater trochanter physis to prevent overgrowth of the trochanter. c In 4 months, the osteotomy is healed
plate for adolescents was performed 1 year after the injury (Fig. 3b). The blade of the plate was inserted through the greater trochanter physis with the goal to reach the apophyseodesis and to prevent overgrowth of the trochanter postoperatively. The limb length equalization was achieved, and the osteotomy healed successfully in 3 months (Fig. 3c). The plate was removed 6 months after the osteotomy. One year after the osteotomy, only partial revascularization of the femoral head had been achieved, while the anterolateral necrotic segment of the femoral head persisted. The left lower limb was 1 cm shorter. During the next year, the shortening progressed, and 3 years after the injury and 2 years after the osteotomy, it reached 2 cm. The necrotic avascular fragment in the weight-bearing area of the femoral head did not heal (MRI scan, Fig. 4). That was the reason for another valgus-extension (valgus 30 deg and extension 20 deg) intertrochanteric osteotomy which was performed 3.5 years after the injury and 2.5 years after the first osteotomy (Fig. 5b). The 120 deg, double-angled blade plate was used for fixation. The shortening of the limb was preoperatively 2.5 cm and postoperatively 0.5 cm. The patient healed without complications, and the following X-ray picture showed subsequent remodelling of the necrotic head fragment. The plate was removed 18 months after the operation.
At check examination 7 years after the injury and 3.5 years after the second osteotomy, the boy was 19 years old and 185 cm high without subjective complaints or functional limitations. He felt just mild pain after strenuous sports activity, e.g., volleyball or biking. The X-ray examination showed mild flattening of the femoral head and a lower CE angle of the acetabulum. However, the necrotic head fragment had remodelled completely (Fig. 5c). The limb shortening was 1.5 cm, hip flexion 0–110 deg, external rotation 0–45 deg, internal rotation 0–15 deg, abduction 0–45 deg, adduction 0–20 deg. The boy is being monitored further.
Discussion Physeal injuries due to gunshots have been reported before, but no reference to an injury to the proximal femur was found in the literature [1, 2, 3, 4, 7, 8]. In our case, we found an incomplete drill hole metaphyseal fracture. Bartlett et al. [1] found the cause of these injuries in lower-velocity projectiles. The injury to the physis and femoral head epiphysis could be the result of both direct mechan-
71 Fig. 4 a MRI scan in the coronal plane shows the extent of the necrotic femoral head fragment 3.5 years after injury. b The same MRI scan in the sagittal plane
Fig. 5 a At 3.5 years after injury and 2.5 years after the first osteotomy, the lateral part of the femoral head is still necrotic. b The valgus-extension intertrochanteric osteotomy is performed. c At 7 years after injury and 3.5 years after the second osteotomy, remodelling of the necrotic femoral head fragment is achieved
ical physeal injury and retinacular vessels injury. Ogden [4] describes the influence of metaphyseal trauma on the physeal function as a type 8 injury. The method of treatment was chosen on the basis of our preliminary positive experience with the treatment of partial femoral head necrosis after femoral neck fractures in children and adolescents (unpublished data). In such cases, we chose either valgus or varus intertrochanteric osteotomy based on the MRI scan showing the extent and localization of the necrosis. In this case, the pathogenetic situation could be different, but the progressive femoral head necrosis had to be solved. With regard to the localization of the necrotic segment in the weight-bearing area and rapid progression of the necrosis, conservative treatment could have led to complete collapse of the femoral head. Double intertrochanteric osteotomy is an extraordinary solution, especially given the possible damage of extracapsular vessels supplying the femoral head. However, the persistence of the necrotic fragment in the weight-bearing area of the femoral head was a greater risk in our opinion. A positive aspect could be the time delay between the two operations allowing a better regeneration of the bone. Other revascularization procedures were not considered relevant [6]. Although in our case the development of posttraumatic osteoarthritis is suspected, we hope our treatment eliminated a total femoral head necrosis and delayed the necessity for total hip replacement for many years.
Acknowledgement The study was prepared with a grant of the Ministry of Health of the Czech Republic (grant IGA MZ ND 7022–3).
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