Pediatric femoral neck fractures: our 10 years of experience

Abstract

Background: Femoral 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.

Methods: The 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.

Results: The 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.

Conclusions: We 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.

Keywords: Avascular necrosis; Delbet classification; Open reduction and internal fixation; Pediatric femur neck fracture; Ratliff.

Fig. 1

Displaced femoral neck fracture in a patient managed with open reduction and internal fixation using partially threaded cancellous screws.

Fig. 2

Displaced femoral neck fracture in a patient managed with open reduction and internal fixation using pediatric dynamic hip screw showing union in follow-up radiographs.

Fig. 3

Complications. (A) Avascular necrosis in a patient managed with pediatric dynamic hip screw. (B) Primary screw cut out immediately post operatively (left) with sequential radiograph (right) showing implant failure. (C) Implant breakage and varus in a patient managed with open reduction and internal fixation using partially threaded cancellous screws. (D) Perforation of the capital epiphysis by the screw. (E) Non-union with neck resorption after failed conservative treatment in hip spica. (F) Implant failure with head collapse.