Current controversies in management of fracture neck femur in children: A review

Abstract

Paediatric femur neck fracture is an uncommon injury and is known for high rate of complications. This in turn, can have significant impact on development of hip and overall function of the child. Controversy prevails in many areas of management and it still remains a difficult injury to manage. Through this paper, an attempt has been made to summarize the current concepts in management and suggest current recommendations regarding the controversies so that these injuries can be managed judiciously. A systematic review was done as per PRISMA guidelines using pre-defined inclusion and exclusion criteria. 18 studies with better scientific evidence after quality assessment were included in the systematic review. Current trends and Controversial issues in management were then identified and discussed. It was observed that existing literature is inconclusive regarding several aspects of management of this injury with no clear guideline available. However, certain recommendations useful for decision making could be made. These injuries should be managed aggressively with operative fixation at the earliest and one should not hesitate to open reduce if acceptable alignment is not obtained after one or two gentle closed manipulations. Choice of implant and their configuration in neck can vary depending on age and weight of patient, type of injury and surgeon's preference. Initial fracture displacement could be considered to be most predictive for development of osteonecrosis of the femoral head, whereas, role of surgical decompression, type of fixation and timing of surgery is still debatable. Functional outcome is primarily affected by osteonecrosis of the femoral head, nonunion and severe coxa vara, whereas mild coxa vara, shortening, and premature closure of physis when considered alone, don't have significant influence on functional outcome in short term. Treatment of fracture neck femur in children is still controversial in many aspects and needs further research. It should be understood that complications can occur regardless of the method of treatment and might reveal their full impact many years after injury. Hence, a guarded prognosis should be explained to the parents and care-givers at the time of injury.

Open reduction versus closed reduction in internal fixation of displaced femoral neck fracture in children: a systematic review and meta-analysis

“…ONFH in children is the most common complication following FNF, with a reported incidence of 0–92% in the literature [ 32 ]. Wang et al [ 29 ] reported that age and initial displacement were independent predictors of ONFH in pediatric FNF and insisted that, to avoid ONFH, adequate reduction is more important than the type of reduction.…”

“…In the current study, the incidence of coxa vara deformity, LLD, and PPC also showed no differences between the ORIF and CRIF groups. Although these conditions may occur alone or in combination [ 21 , 28 , 32 ], the consensus is that the incidence of coxa vara deformity is related to reduction status, which means that its likelihood could be diminished with anatomical reduction and internal fixation [ 34 , 38 ]. Although our current synthetic results did not reveal the superiority of ORIF over CRIF with respect to complications, theoretically, ORIF is more beneficial than not in treating FNF because it is required to avoid an unacceptable reduction status, which can lead to serious complications.…”

Bilateral Non-traumatic Neglected Femoral Neck Fracture in a Healthy Adolescent: A Case Report and Review of Literature

“…Treatment of femoral neck fracture in children is controversial in many aspects [ 14 ]. Due to the rare incidence, there is a scarcity of literature about the management of atraumatic bilateral femoral neck fractures in children.…”

Pediatric Femoral Neck Fractures: Our Institutional Experience of 5 Years

“…However, the blood vessels cannot cross the open physis, hence blood supply to the femoral head is critical in children and can be easily disrupted by a fracture. [14][15][16][17] Hence, AVN is the most common and damaging complication of pediatric femoral neck fractures. 18 The risk of AVN depends on several factors, including age, degree of initial displacement of the fracture, time to surgery, and the method of fixation.…”