Pediatric Femoral Neck Fractures: Our 10 Years of Experience

Abstract

BackgroundFemoral neck fractures are rare injuries in children, but the high incidence of long term complications make it an important clinical entity. The aim of this retrospective study was to analyze the clinical outcomes of pediatric femur neck fractures that we managed over a 10 year period.MethodsThe study included 36 children (20 boys and 16 girls) who sustained femoral neck fractures and completed a minimum follow-up of one year. The children were treated either conservatively, or by open reduction and internal fixation (ORIF), or closed reduction and internal fixation (CRIF). The outcomes were analyzed using Ratliff criteria and a detailed record of complications was kept for all patients.ResultsThe mean age of included patients was 10 years (range, 3 to 16 years) and the average follow-up was 3.2 years (range, 1.1 to 8.5 years). Based on Delbet's classification system, there were 0 type I (transepiphyseal), 16 type II, 11 type III, and 9 type IV fractures. There were 8 undisplaced fractures, 4 of which later displaced after being managed initially in a hip spica. A satisfactory outcome was obtained in 27 (75%) children. Avascular necrosis (AVN) was the most common complication. It was seen in 7 of our patients, all of whom had an unsatisfactory outcome. Other complications included three cases each of coxa vara, non-union, and arthritic changes; and one case each of infection, primary screw perforation of head, and premature epiphyseal closure. Complications were lowest in the group treated by ORIF. Only 2 patients managed exclusively by conservative treatment ultimately achieved a satisfactory outcome.ConclusionsWe believe that internal fixation of pediatric femoral neck fractures is preferred whenever feasible because conservative treatment carries a high risk of failure of reduction. Aggressive operative treatments aimed at anatomical reduction should be the goal and there should be no hesitation in choosing ORIF over CRIF. Outcome of patients is influenced primarily by development of AVN which occurs as an independent entity without much relation to the mode of treatment carried out.

Is Urgent Treatment of Pediatric Neck Femur Always Needed?

“…This data is in accordance with previous published series [13,14,16]. 5 cases (26%) of avascular necrosis featured in our study which is quite high compared to the newly reported data but is in accordance with the previously mentioned incidence of about 17%-47% cases [10,[15][16][17][18][19]. we explain our higher rate of AVN to late overall intervention than the urgent and emergency treatment in current series in literature our mean time of surgery after admission was 4.5 days [20][21][22].…”

“…The risk of AVN depends on several factors which include age, degree of initial displacement, type of fracture, time to surgery, and method of fixation [13,23,24]. The most important factor is likely the severity of vascular compromise sustained at the time of trauma which may or may not change time of surgery after trauma [17]. It was not justifiable for early surgical intervention before proper optimization of patient for fear of AVN as the AVN in children behaves like perthes with ample scope for remodeling of head and reasonable functional outcome.…”

“…Most cases of coxa vara, delayed union or nonunion in the series of Ratliff and Lam were treated without internal fixation [1,13]. Due to inherent nature of spica being open at top there is natural tendency of fracture to get displaced if treated without internal fixation, this can be also reason of high coxa vara and non-union in earlier series [17]. Superficial erythema and tenderness over skin overlying moors pin in 2 cases responded to oral antibiotics we presume it is related to hygiene in spica, usually poor in developing countries.…”

Femoral neck fracture treatment methods and results evaluation in children in a 5 year period Mashhd, Iran

“…However, in our study movement limitation is the most common complications. Other complications in their study included, nonunion, coxavara and arthritic changes which is matched our results to some extent 10 . To wrap it up, operative treatments such as open reduction and internal fixation is preferred in comparison to conservative methods, because these methods lead to less serious complications.…”

A Rare Case Report on Bilateral Intertrochanteric Fractures in a Child Following Child Abuse

“…Type-I fractures are transepiphyseal separations, with or without dislocation of the femoral head from the acetabulum, type II are transcervical, type III are cervicotrochanteric and type IV are intertrochanteric fractures. Though incidence of paediatric hip fractures are low, they need proper treatment since they are associated with high incidences of complications like avascular necrosis of head of femur, coxa vara, nonunion, premature physeal closure, delayed union and shortening of limb [6]. Incidence of avascular necrosis of head of femur is 100% in type I, 50% in type II, 27% in type III and 14% in type IV Delbets fractures.…”