Fractures of the head and neck of the femur in children: an outcome study

Clinical features of pediatric femoral neck fractures and analysis of risk factors for avascular necrosis of the femoral head: A retrospective case-control study of 45 patients

OBJECTIVES

To summarize the clinical features of pediatric femoral neck fractures and analyze the risk factors for avascular necrosis of the femoral head.

METHODS

A retrospective analysis of the case data of pediatric femoral neck fractures treated in our hospital from January 2010 to December 2022, including gender, age, fracture type, causative factors, and surgical details. The occurrence of avascular necrosis of the femoral head was recorded and risk factors were analyzed.

RESULTS

From January 2010 to December 2022, a total of 45 cases of femoral neck fractures were treated in our hospital with a median age at onset of 93 months (IQR=81) and a median time from injury to surgery of 96 hours (IQR=46). Closed reduction was performed in 36 cases, while open reduction was performed in 9 cases. Avascular necrosis of the femoral head occurred in 29 cases postoperatively, while it did not occur in 16 cases. Increased time from injury to surgery and greater degree of fracture displacement were independent risk factors for avascular necrosis of the femoral head. The risk of avascular necrosis in Garden IV type femoral neck fractures was significantly higher than in Garden II and III type patients. An injury-to-surgery time exceeding 82.5 hours was identified as a critical threshold for the development of avascular necrosis of the femoral head.

CONCLUSION

Pediatric femoral neck fractures have a low incidence rate and are mostly caused by high-energy trauma, often resulting in severe injuries. Therefore, actively maintaining stable vital signs and properly managing associated injuries, timely surgical intervention for femoral neck fractures, achieving good reduction and fixation of displaced fractures are crucial in the treatment of pediatric femoral neck fractures.

Outcome of early versus delayed presentation of proximal femur fractures in children: A prospective cohort study

OBJECTIVE

We hypothesized that the exact time of fixation of paediatric proximal femur fractures will have an effect on the ultimate clinical and radiological outcome. This article aimed to compare the clinical-radiological outcomes in paediatric proximal femur fractures having early and delayed presentation.

METHODOLOGY

A prospective cohort study was conducted from January 2019 to November 2022 in patients of age of 5 to 16 years presented with proximal femur fracture and divided into two groups: group A: early presentation, presented <48hours of injury; group B: delayed presentation, presented >48hours of injury. Patients underwent internal fixation treatment modality and followed up to assess clinical outcomes and radiological outcomes, and final outcome was assessed as per Ratliff's criteria.

RESULTS

In the study of 44 patients, 72.72% were male, and 27.27% were female, with male-to-female ratio to be 2.6:1. The commonest mode of injury was fall from height accounting for 52.27% followed by road traffic accidents (RTA) in 38.63%. The most common fracture type observed was Delbet type II, which was observed in 43.18%. There was significant shorter duration of surgery in group A (p-value=0.013), VAS score (p=0.045), and limb length discrepancy (p=0.022). Also, there was a statistical difference in AVN (p-value=0.0295) and growth disturbance (p-value=0.0394) between two groups. Also, there was statistically significant difference between Ratliff's criteria two groups (p-value=0.030).

CONCLUSION

Early presentation has shorter duration of surgery, less VAS score at final follow-up, and less limb length discrepancy, less development of complications like avascular necrosis of the femoral head, and growth disturbance.

LEVEL OF EVIDENCE

III.

[Outcomes and complications of open versus closed reduction and internal fixation for Delbet type Ⅱ and Ⅲ hip fractures in children and adolescents]

OBJECTIVE

To compare the outcomes and complications of open versus closed reduction and internal fixation for Delbet type Ⅱ and Ⅲ hip fractures in children and adolescents.

METHODS

We retrospectively analyzed the data of 42 patients with Delbet type Ⅱ (22 cases) and Ⅲ (20 cases) hip fractures (including 24 male and 18 female patients with a mean age of 8.19± 3.23 years, range 2-15 years) admitted in the Fifth and Third Affiliated Hospital of Southern Medical University from January, 2013 to January, 2022. Nineteen of the patients received closed and 23 underwent open reduction and internal fixation. The operation time, postoperative healing time, and Ratliff standard hip function results were compared between the two groups, and the incidences of such complications as premature epiphyseal closure and femoral head necrosis were analyzed.

RESULTS

All the patients were followed up for 13-84 months (mean 36.04±8.23 months). The operation time of closed reduction and internal fixation was significantly shorter than that of open surgery (68.23±24.68 vs 119.71±32.75 min, P < 0.05). All the patients showed good fracture healing after the operations with similar healing time between the two groups (3.32±0.31 vs 3.18±0.20 months, P > 0.05). The rate of excellent and good hip joint function was 90.48% in the overall patients and showed no significant difference between the two groups (17/19 vs 21/23, P > 0.05). The incidences of premature epiphyseal closure (3/19 in closed vs 4/23 in open reduction group, P > 0.05) and femoral head necrosis (2/19 vs 1/23, P > 0.05) were comparable between the two groups.

CONCLUSIONS

In children and adolescents, open reduction can achieve definite surgical effect for Delbet type Ⅱ and Ⅲ hip fractures, but closed reduction and internal fixation are recommended when anatomic reduction can be achieved. Premature epiphyseal closure and femoral head necrosis are common and serious complications of these fractures.

The incidence and risk factors for femoral head necrosis after femoral neck fracture in pediatric patients: a systematic review and meta-analysis

BACKGROUND

The incidence of avascular necrosis (AVN) after pediatric femoral neck fracture (PFNF) in the literature varies widely, and the risk factors associated with AVN after PFNF are controversial. Therefore, this study aimed to accurately investigate the incidence of AVN after PFNF and systematically evaluate and meta-classify their risk factors.

METHODS

A comprehensive search was performed of PubMed, Web of Science, and Embase. The pooled rate and 95% confidence interval (CI) were used to assess the incidence of AVN after PFNF, and pooled odds ratio (OR) were calculated to measure the effect sizes. In addition, we performed subgroup, stratified, and publication bias analyses.

RESULTS

A total of 30 articles were included in our meta-analysis, with 303 AVN cases among 1185 patients. The pooled incidence of AVN after PFNF was 22% (95% CI 18%, 27%). Subgroup analyses indicated Delbet type I-IV fracture incidences with AVN of 45%, 32%, 17%, and 12%, respectively. The incidence of AVN after PFNF in Asia was 19%, lower than in Africa at 36%, Europe at 26%, and North America at 23%. In addition, the larger sample size group and the earlier published literature group showed a higher incidence of necrosis. Stratified analyses showed that patient age and Delbet fracture classification were both important factors affecting AVN after PFNF (OR = 1.61, p = 0.02 and OR = 3.02, p < 0.001, respectively), while the time to treatment was not (OR = 0.9, p = 0.71).

CONCLUSION

The pooled incidence of AVN after PFNF was ~ 22%; furthermore, the available evidence demonstrates that patient age and Delbet type of fracture were important influencing factors of AVN after PFNF.

Do the Number, Size, and Position of Partially Threaded Screws Affect the Radiological Healing of Surgically Treated Displaced Femoral Neck Fractures? A Review of 136 Children

Background and Objectives: The quantity, size, and position of implants might affect the fracture healing process of surgically treated displaced pediatric femoral neck fractures (PFNFs). The aim of this retrospective multicenter study was to evaluate the correlation between the time needed to achieve radiological union and the number, size, and location of the partially threaded cannulated screws (PTCSs) in children with displaced PFNFs. Materials and Methods: A retrospective review of 136 children (mean age: 10.6 ± 3.8 years) with displaced PFNFs treated by two (n = 103) or three (n = 33) PTCSs was carried out. Student’s t-tests, one-way ANOVA, Cox regression analysis, and multiple linear regression analyses were performed to investigate the variables affecting the time needed to achieve radiological fracture healing according to the number, size, and position of PTCSs, as assessed on plain radiographs. Results: A total of 132 hips achieved union at an average of 3.2 ± 1.6 months after the initial surgery. The time needed to achieve union in the patients treated with two or three PTCSs was comparable (p = 0.36). Among the fractures treated by two PTCSs, the time needed to achieve union did not correlate with the size of the implant (p = 0.122), or with the angulation between the PTCSs on anterior–posterior (p = 0.257) and lateral radiographs (p = 0.547). The time needed to achieve union in the fractures that were fully compressed by the implants was similar to the partially compressed fractures (p = 0.08). Conclusions: The number, size, and position of the PTCSs do not affect the radiological healing in the children with displaced PFNFs treated surgically.

Postoperative avascular necrosis of the femoral head in pediatric femoral neck fractures

This study aimed to evaluate the relevant factors of postoperative avascular necrosis of the femoral head (AVN) in children with femoral neck fracture. This study retrospectively analyzed the clinical data of 28 children with femoral neck fractures treated at our center between July 2016 and January 2019. The average age was 9.3 (range, 4.4–14) years with 75% male participants. Fracture classification was based on the Delbet classification: there were four, seven, 15, and two cases of type I, II, III, and IV fractures, respectively. Displacement degree was based on the Garden classification. Sixteen cases had insignificant displacement (Garden types I and II), six had medium displacement (Garden type III), and six had significant displacement (Garden type IV). There were six early (≤24 hours) and 22 delayed (>24 hours) surgeries. Twenty-three patients had satisfactory reduction, and five had unsatisfactory reduction. The mean postoperative follow-up period was 15.7 (range, 12–36) months. Follow-up was evaluated using the Ratliff scoring standards. The correlation between age, fracture classification, displacement degree, surgery timing, reduction quality, and other factors and AVN occurrence was statistically analyzed. Among 28 children, AVN was found in six cases. There were statistically significant differences in displacement degree (P = 0.001) and reduction quality (P = 0.001), while the occurrence of AVN did not significantly differ with sex (P = 0.117), age distribution (P = 0.218), fracture classification (P = 0.438), surgery timing (P = 0.255), and mechanism of injury (P = 0.436). The results of logistic regression analysis showed that displacement degree was a relevant risk factor (P = 0.049, odds ratio [OR] = 8.391, 95% confidence interval [CI]: 1.004−70.117), while reduction quality was not (P = 0.075, OR = 14.536, 95% CI: 0.757−278.928). Although the development of AVN in children with femoral neck fractures may be related to many factors, the results of this research suggest that there is a significant correlation between displacement degree and AVN occurrence.

Pediatric pathological subtrochanteric fracture treated with an adult proximal humerus polyaxial locking plate: A case report

Pediatric subtrochanteric fractures are relatively rare. There are some surgical options with various plate techniques. Here, we report the first description of a pediatric pathological subtrochanteric fracture treated with an adult proximal humerus polyaxial locking plate and describe the good clinical outcomes achieved. A 10-year-old boy had a pathological subtrochanteric fracture. A non-contact bridging proximal humerus osteosynthesis plate was used. Although this is designed for the adult proximal humerus, its size and shape were considered to fit the pediatric proximal femur. In addition, this is a polyaxial locking plate with a choice of screw insertion directions. During surgery, it was possible to determine an appropriate plate installation position and screw direction in consideration of the location of pathological lesions, the bone shape, and the femoral neck angle. Twelve months postoperatively, the fracture was healed, and pathological lesion consolidated without obvious growth failure.

Outcomes of operative management in the delayed presenting neck of femur fractures in children: A case series

Introduction

Fracture neck of femur in pediatric age group occurs due to high energy trauma and is an uncommon entity with high complication rate. No uniform guidelines are present to manage these fractures, especially in delayed presentation of fracture neck of femur as a smaller number of such cases were reported.

Cases

Eight children (nine hips), five boys and three girls of age <15 years, were operated on. The mean delay in surgery time was 8.6 days (range: 5-22 days). The mean union time was 13.44 weeks. The mean follow-up was 20.88 months (range: 12-36 months). All the cases were managed with closed or open reduction followed by internal fixation with or without hip spica application and resulted in satisfactory outcomes in most of the cases.

Conclusion

Anatomical reduction (open or closed) and fixation reduce the risk of complications even in delayed presentation if the orthopedic surgeon is familiar with the management.

Ipsilateral femoral neck and shaft fracture in children: Two case reports

RATIONALE

Pediatric femoral shaft combined with ipsilateral femoral neck fractures are very rare but challenging injuries fraught with the development of avascular necrosis, coxa vara, and leg length discrepancy. Majority of the previous reports indicated the neck femur fracture was fixed with cannulated screws or/and pins, femoral shaft fracture was stabilized with a plate and screws. However, we used cannulated screws combined with elastic stable intramedullary nails to minimally invasive procedures treat this type of injury and achieved good follow-up results.

PATIENT CONCERNS

A 7-year-old boy (Case 1) was hospitalized due to a traffic accident resulting in swelling and deformity of the right thigh accompanied by limited mobility of hip and knee. A 5-year-old male child (Case 2) presented with pain and swelling in the bilateral lower limb after fall from approximately 12 feet.

DIAGNOSES

Physical examination, X-ray film, and computed tomography were performed. Both patients were diagnosed with ipsilateral femoral neck and shaft fracture.

INTERVENTIONS

The fractures were reduced closed by image-intensifier imaging. Two partially threaded cancellous screws were used to fix femoral neck fracture, and elastic intramedullary nails were performed to stable the femoral shaft fracture. Postoperatively, the patients were immobilized in a one-and-a-half hip spica cast for six weeks. The internal fixations were removed after one year.

OUTCOMES

Case one was follow-up at 14 months and the other one was followed up for 3 years. And at the last follow-up showed a normal and painless hip function. No clinical complications were found during follow-up visit, including head penetration, implant failure, fracture nonunion, avascular necrosis and hip varus deformity.

LESSONS

Clinician should carefully check and read relevant imaging data to avoid missed diagnosis. And the internal fixation method described in this paper may be more minimally invasive.

Fractures of the trochanteric region in children and young adolescents-a treatment algorithm for a rare injury

For femoral fractures of the trochanteric region in children and adolescents, only two mechanisms have been identified to cause a fracture of the proximal femur: high-energy trauma or predisposing bone pathologies with inadequate trauma (e.g., simple fall, movement). We identified 20 patients between 1993 and 2018 with a trochanteric fracture under the age of 18 (12 males; 8 females; mean age, 12 years; range, 4-17 years) who were treated operatively at our department. The mean follow-up of all patients was 50.06 months. All 20 patients were treated operatively. Complications occurred after a mean time of 6.27 months (range, 0.47 to 12.07 months) in two patients. Harris Hip Score was evaluated in all patients with a mean score of 94.16 (range 11 to 100). Eighty-five percent of the patients reached an excellent clinical outcome after treatment. Trochanteric femoral fractures in children and adolescents are very rare accounting for only 1% of all trochanteric fractures. Excellent long-term results can be achieved with an adequate fracture reduction.Conclusion: Physicians treating pediatric trauma have to be aware of other predisponding diseases when low-energy trauma leads to a trochanteric fracture as in this study, 50% of the trochanteric fractures were associated with bone pathologies. What is Known: • Trochanteric femoral fractures in children and adolescents are very rare • In all patients with trochanteric femoral fractures, malignancies have to be ruled out What is New: • Awareness of an underlying bone pathology in a high number of cases • Awareness for necessity of a good fracture reduction leading to highly satisfactory results.

The clinical and radiographic characteristics of avascular necrosis after pediatric femoral neck fracture: a systematic review and retrospective study of 115 patients

BACKGROUND

Avascular necrosis (AVN) after pediatric femoral neck fracture (PFNF) showed poor prognosis, but its clinical and radiographic characteristics remained unclear.

METHODS

A systematic review and a retrospective study were performed to evaluate the clinical and radiographic characteristics of patients with AVN after PFNF.

RESULTS

A total of 686 patients with PFNF and 203 patients with AVN from 21 articles were analyzed. Ratliff's classification was used in 178 patients, with types I, II, and III AVN accounting for 58.4%, 25.3%, and 16.3%, respectively. Ratliff's assessment was used in 147 patients, of whom 88.4% had an unsatisfactory prognosis. In retrospective study, 115 patients with a mean age of 13.6 ± 2.0 years were included. The mean interval between AVN and PFNF was 13.7 ± 9.5 months. At the time of diagnosis, 59.1% cases were symptomatic and 65.2% progressed to collapsed stage. Fifty (43.5%), 61 (53.0%), and 4 patients (3.5%) were defined as types I, II, and III , respectively, via Ratliff's classification. Thirteen (11.3%), 40 (34.8%), and 62 patients (53.9%) showed types A/B, C1, and C2 disease, respectively, via the JIC classification. Multivariate analysis demonstrated a strong relation between collapsed stage and symptomatic cases (OR = 6.25, 95% CI = 2.39-16.36) and JIC classification (OR = 3.41, 95% CI = 1.62-7.17).

CONCLUSION

AVN after PFNF showed a tendency toward extensive necrotic lesions, presumably resulting in a rapid progression of femoral head collapse. And the symptoms and the JIC classification are other two risk factors of collapse progression.

Does the timing of treatment affect complications of pediatric femoral neck fractures?

Objectives

Pediatric femoral neck fractures were reviewed to compare complications with the time of presentation.

Methods

34 pediatric femoral neck fractures were studied to detect union time, avascular necrosis, premature physis fusion, and the neck-shaft angle. All complications were comparable between both groups.

Results

The mean union time was more in late presented group. Four children developed AVN. The neck shaft angle and pre mature fusion of growth plate were same in both groups.

Conclusions

The frequency of the complications except union time in pediatric neck femur fracture is comparable in early and late presented groups.

Extra-articular proximal femur fractures in children and adolescents treated by elastic stable intramedullary nailing

PURPOSE

Extra-articular proximal femur fractures (EPFF) remain challenging for their intrinsic instability. The aim of this study is to evaluate the results of elastic stable intramedullary nailing (ESIN) of extra-articular proximal femur fractures in children and adolescents.

METHODS

A retrospective monocentric study of children treated by ESIN for EPFF between 2012 and 2018 was conducted. We included all patients sustaining a fracture within 10% of the femur length below the lesser trochanter. Studied data were age, sex, femur length, fracture distance below the lesser trochanter, number of days of hospitalization, time to nail removal, and complications. Beaty's criteria and the titanium elastic nailing (TEN) outcome measure scale were used to evaluate radiologic outcome and assess clinical recovery, respectively.

RESULTS

A total of 24 cases were reviewed (18 males, 6 females). Mean age was 8.23 years (range 5-13). Mean duration of hospitalization was 3.7 days (range 2-12). Mean time to nail removal was 28 weeks (range 12-53). Malalignment was observed in five patients, but in all cases, angulation did not exceed 10°. No limb length discrepancy was observed. Twenty out of 24 patients had excellent Beaty's radiological and TEN clinical outcome scores. No poor results were observed.

CONCLUSIONS

The results of our study show that good outcomes following surgical treatment by ESIN should be expected in children younger than 14 years of age with displaced EPFF. Excellent radiological and clinical outcomes were observed in 83.7% of the cases, with a low rate of complications and short hospital stay.

Management of Pediatric Femoral Neck Fracture

In the pediatric population, femoral neck fracture is a relatively uncommon injury with a high complication rate, despite appropriate diagnosis and management. The anatomy and blood supply of the proximal femur in the skeletally immature patient differs from that in the adult patient. Generally, these fractures result from high-energy trauma and are categorized using the Delbet classification system. This system both guides management and aids the clinician in determining the risk of osteonecrosis after these fractures. Other complications include physeal arrest, coxa vara, and nonunion. Multiple fracture fixation methods have been used, with the overall goal being anatomic reduction with stable fixation. Insufficiency fractures of the femoral neck, although rare, must also be considered in the differential diagnosis for the pediatric patient presenting with atraumatic hip pain.

Intra-articular loose body caused by avascular necrosis of the femoral head in children

In children, avascular necrosis of the femoral head occurs easily because of the difference in the domination of blood flow compared with that in adults. Here we report a rare case of a 12-year-old girl who sustained a femoral neck fracture. The femoral head collapsed after open reduction and internal fixation. The hip developed into subluxation because of the gradually enlarged loose body in association with avascular necrosis. These results might be explained by the fact that blood circulation from the ligamentum teres temporarily increases during the ages of 8-12 years.

Biomechanical study of 16-mm threaded, 32-mm threaded, and fully threaded SCFE screw fixation

BACKGROUND

The initial goals of the treatment of slipped capital femoral epiphysis (SCFE) are to stabilize the epiphysis, prevent slip progression, and avoid complications. In situ fixation with a single screw is the most accepted procedure to provide an optimal fixation, but fixation failure and slip progression suggest that the procedure might be improved. The aim of the present study was to biomechanically compare partially threaded screws (16 mm and 32 mm) and fully threaded screws in an in vitro porcine model.

METHODS

An unstable/acute SCFE was created in 18 skeletally immature porcine femurs through a type 1 Salter-Harris fracture. Each femur was fixed using a 6.5-mm stainless-steel cannulated screw inserted through the physis under fluoroscopic guidance. The screw was either 16 mm threaded, 32 mm threaded, or fully threaded (n=6 each group). Each specimen was cyclically tested to failure fixation by anterior-to-posterior loading through the femoral head.

RESULTS

No significant difference was detected between the Newton cycles to failure of the 3 screw-thread groups. The 16-mm threaded group had the highest frequency of femoral neck failure.

CONCLUSIONS

The 16-mm threaded screws had the highest rate of neck failure and did not demonstrate additional fixation stability over the 32-mm threaded and fully threaded screws. As femoral neck fracture is a rare but devastating complication in pediatric patients, clinical use of the 32-mm threaded and fully threaded screws may be indicated in SCFE fixation.

CLINICAL RELEVANCE

The use of 32-mm or fully threaded screws is a valid SCFE treatment option. The increased number of threads in the metaphysis with these screws may confer additional biomechanical strength to the femoral neck.