Does early stable fixation reduce complications in paediatric femoral neck fractures?

Abstract

The primary objective of this study was to juxtapose the union rate and incidence of complications in paediatric patients presenting early (≤ 7 days) following injury with children presenting later (> 7 days) with femoral neck fractures. This critical appraisal evaluated 15 patients according to their timing of presentation and surgery from the initial day of injury (Group A: operated ≤ 7 days or Group B: > 7 days of injury). Patients with traumatic femoral neck fractures with Delbet 1 to 4 subtypes who were skeletally immature (age ≤ 16 years) were included in the study. Pathological fractures and post-infective fractures were not included. Each patient's secondary loss of reduction was calculated by measuring the Neck shaft angle (NSA) on the immediate post-operative radiograph and at the union. A change in NSA of ≥ 5 degrees was considered a significant loss of reduction. Ratliff's Criteria was used to analyze the final result, and a thorough record of complications was kept. There were no significant variations in the two groups' with respect to distributions of age, sex, injury mechanism, or fracture pattern. The most frequent injury culprit in both groups was falling from a height. Type II fracture pattern (54.54%) was more common in group A, while Type III and Type II fracture pattern was equally distributed in group B. In group A, the mean operation time was 55 ± 8.25 minutes, whereas in group B, it was 65 ± 15 minutes (p-value > 0.05). In group A, 90.9% of patients underwent CCS fixation, and in group B, 75% underwent fixation by CCS. The quality of reduction in post-operative radiographs was anatomical in 10 (90.9%) patients and unacceptable in 1 (9.1%) patient. In group B, 2 (50%) patients had an anatomical reduction, while 2 (50%) patients had an unacceptable reduction. Timing of reduction and its association with complications showed that early stable reduction and fixation decrease the occurrence of complications in femoral neck fractures (p-value = 0.033). Fracture union was seen in all our patients in both groups and none of our patients underwent non-union. The mean union time was 11.11 ± 7.06 weeks in group A and 16.5 ± 2.59 weeks in group B (p-value = 0.0189). In group A, only 1 (9.1%) patient developed coxa vara. In group B, out of 4 patients, the femoral head of one patient underwent avascular necrosis, one patient exhibited coxa vara, and 1 patient developed premature physeal closure with limb length inequality. Management of femoral neck fractures in children is challenging because of the paediatric bone's peculiar anatomic and physiological considerations. In our study, patients operated within 7 days developed fewer complications as compared to patients who were operated after 7 days, which was statistically significant. Although AVN is a frequent adverse consequence of pediatric femoral neck fractures, early reduction and stable fixation lowers AVN rates, as observed in our study. Our short-term functional and radiological results using the Ratliff scoring system were comparable to previous studies owing to stable anatomic reduction. Based on our findings and the existing literature, we emphasize long-term follow-up and recommend an early stable anatomic reduction in the treatment of paediatric femoral neck fractures.

Keywords: CCS (cannulated cancellous screws); Paediatric femoral neck fracture; avascular necrosis (AVN); coxa vara; neck shaft angle (NSA); ratliff’s criteria.

Figure 1

Case example of Delbet Type III fracture neck of femur (Group A). A, B. Pre-operative radiograph showing Delbet Type 3 left hip fracture in a 6 year old child operated 2 days after sustaining initial injury (Group A). C. Post-operative radiograph showing good reduction and alignment after fixation with 2 CCS. D. Plain radiograph at 14 months follow-up showing uncomplicated union.

Figure 2

Ratliff scoring of the of Delbet Type III fracture neck of femur (Group A). A. Immediate post-operative radiograph of the patient showing NSA of 137.4 degrees. B. Final follow-up radiograph showing NSA of 135.9 degrees. Secondary loss of reduction in NSA is 1.5 degrees (clinically insignificant). Patient was classified as having a “good” outcome according to Ratliff system.

Figure 3

Case example of Delbet Type II fracture neck of femur (Group A). A, B. Pre-operative radiographs showing Delbet Type II left hip fracture in a 13 year old female child operated 3 days after the initial injury (Group A). C. Post-operative radiograph showing excellent reduction and alignment after fixation with 3 CCS. D. Plain radiograph at 18 months follow-up showing good union.

Figure 4

Ratliff scoring of the of Delbet Type II fracture neck of femur (Group A). A. Immediate post-operative radiograph of the same patient showing NSA of 133.8 degrees. B. Final follow-up radiograph showing NSA of 133.9 degrees. The secondary loss of reduction in NSA is 0.1 degree and overall patient was classified as having a “good” outcome according to Ratliff system.

Figure 5

Case example of Delbet Type III fracture neck of femur (Group B). A, B. Pre-operative radiograph showing Delbet Type III right hip fracture in a 5 year old male child operated 20 days after the initial injury (Group B). C. Post-operative radiograph showing “fair” quality of reduction & alignment after fixation with 3 CCS. D. Radiograph at 18 months follow-up showing union with development of coxa vara.

Figure 6

Ratliff scoring of the of Delbet Type III fracture neck of femur (Group B). A. Immediate post-operative radiograph of same patient showing NSA of 128.1 degrees. B. Final follow-up radiograph showing NSA of 115.3 degrees (Coxa Vara). The secondary loss of reduction in NSA is 12.8 degrees and overall patient was classified as having a “fair” outcome according to Ratliff system.

Figure 7

Case example of Delbet Type II fracture neck of femur (Group B) showing development of avascular necrosis of femoral head. A, B. Pre-operative radiograph showing Delbet Type II fracture of left hip in a 10 year old child operated 14 days after the initial injury (Group B). C. Post-operative radiograph showing poor quality of reduction and fixation of fracture with 2 CCS. D. Plain radiograph at 8 months follow-up after implant removal showing flattening and collapse of femoral head indicative of avascular necrosis of left femoral head. The patient had complaints of a painful limp along with restricted movements of the left hip joint. Patient was classified as having a “poor” outcome according to Ratliff system.

Figure 8

Case example of Delbet Type III fracture neck of femur (Group B) showing premature physeal closure. A, B. Pre-operative radiograph showing Delbet Type III fracture of left hip in a 11 year old male child operated 12 days after the initial injury (Group B). C. Post-operative radiograph showing good quality of reduction & fracture fixation with paediatric DHS. D. Plain radiograph at 12 months follow-up showing union with premature physeal closure. The patient also had a limb length discrepancy of 1.5 cm with “good” outcome according to Ratliff system.