Delayed fixation of displaced type II and III pediatric femoral neck fractures

Abstract

Background:Time from injury to fixation of femoral neck fractures has been postulated as a vital determinant for rate of complications; however, no prospective study is available in the English literature. Delay, unfortunately, is inevitable in developing countries. The aim of the present study is to retrospectively review the outcome after delayed fixation of displaced type II and III femoral neck fractures in children.Materials and Methods:Using a standard assessment chart, we retrospectively reviewed medical records of all pediatric patients having femoral neck fractures presenting to our institution from June 1999 to May 2006. Inclusion criteria were children between 5 and 15 years of age sustaining displaced Delbet type II and III femoral neck fractures having a complete follow-up of at least 2 years. Patients with known metabolic disease, poliomyelitis or cerebral palsy, were excluded from the study. After application of inclusion and exclusion criteria, 22 patients having 22 fractures (13 type II and 9 type III) were studied. Surgery could be performed after a mean delay of 11.22 days (ranging from 2 to 21 days). Closed reduction was achieved in 14 cases and 8 cases required open reduction through anterolateral approach.Result:Osteonecrosis was noted in eight patients (36.37%) who included two of nine patients (22.22%) operated in the first week, three of eight patients (37.51%) operated in the second week, and three of five patients (60%) operated in the third week of injury. Nonunion was seen in four (18.18%) cases, and two of them were associated with failure of implants. One was treated by valgus osteotomy and the other by Meyer's procedure. Fractures united in both children but the latter developed avascular necrosis. Functional results, as assessed using Ratliff's criteria, were good in 14 (63.63%), fair in 2 (9%), and poor in 6 (27.27%) patients.Conclusion:Delay in fixation, type of fracture, and ability to achieve and maintain reduction are factors primarily responsible for the outcome. We also found that delay after the first week further adversely affects the outcome.

Management of femoral neck fractures in children: Experience of a short series in a developing country

“…In another series of Azam et al ,[18] AVN developed despite excellent reduction in five patients, of whom two were operated in the 2 nd week and three in the 3 rd week. They attributed delayed fixation as a contributing factor after considering other variables.…”

“…In developing country, delayed management of pediatric fractures is common because of ignorance, illiteracy, tendency to go to bone setters, financial constraints, and late referral by hospital and local conditions such as inadequate equipment. [71718] In case of early admission in our context, delay to surgical intervention was explained by the fact that operating room entrance fee, implants, and pharmaceutical product were bought by the parents who have no health insurance in the majority of cases. Besides, some parents refused surgical intervention.…”

Proximal femoral fractures in children and adolescents

“…9,13,15,16--20 Two recent studies retrospectively evaluated the outcomes of hip fractures treated more than 1 week after injury. 18,19 As expected, there were poor outcomes and a higher rate of avascular necrosis in those treated more than 1 week after injury. Some authors argue that the initial severity of trauma may be more important than the timing with respect to development of osteonecrosis.…”

Case Report: Bilateral Femoral Neck Fractures in a Child and a Rare Complication of Slipped Capital Epiphysis After Internal Fixation

“…Most of the nontraumatic bilateral femoral neck fractures have been reported in adults or in patients with metabolic bone diseases or malignant diseases of other organs or postseizure [2,5,6,18]. Traumatic femoral neck fractures in children are associated with high rates of complications [1,20] owing to the typically high-velocity nature of the fractures, the unique vascularity of the proximal femur, open physes, and in developing countries a frequently delayed presentation to healthcare facilities. Complications include avascular necrosis of the femoral head, nonunion, posttraumatic coxa vara, growth arrest, infection, and chondrolysis [4].…”