Displaced femoral neck fracture in children and adolescents: closed versus open reduction--a preliminary study

Does open or closed reduction with internal fixation reduces the incidence of complications in neck of femur fractures in pediatrics: a meta-analysis and systematic review

The neck of femur fracture (FNF) in children is a rare injury with a high incidence of complications such as avascular necrosis (AVN), coxa-vara and nonunion. The aim of this review is to compare the incidence of complications between open reduction with internal fixation (ORIF) and closed reduction with internal fixation (CRIF) of FNF in children. Two independent reviewers searched EMBASE, MEDLINE, COCHRANE and PUBMED databases from inception until April 2022 according to the preferred reporting items for systematic reviews and meta-analyses guidelines. Studies included comparison of complications between open and closed approaches with fixation of FNF in patients less than 18 years old. Publication bias was assessed using Egger's test while the Newcastle-Ottawa tool was used to assess the methodological quality of the studies. A total of 724 hip fractures from 15 included studies received either ORIF or CRIF. Overall, the rate of AVN was approximately 21.7% without statistical significance between both reduction methods [relative risk (RR) = 0.909, using fixed effect model at 95% confidence interval (CI, 0.678-1.217)]. No significant heterogeneity among AVN studies ( I2  = 3.79%, P  = 0.409). Similarly, neither coxa-vara nor nonunion rates were statistically significant in both treatment groups (RR = 0.693 and RR = 0.506, respectively). Coxa-vara studies showed mild heterogeneity ( I2  = 27.8%, P  = 0.218), while significant publication bias was encountered in nonunion studies ( P  = 0.048). No significant difference in the incidence of AVN, coxa-vara and nonunion between ORIF or CRIF of FNF in children. High-quality studies as Randomised Controlled Trials can resolve the inconsistency and heterogeneity of other risk factors including age, initial displacement, fracture type, reduction quality and time to fixation.

Open versus closed reduction and internal fixation in children with femoral neck fractures. Systematic review and meta-analysis of the literature

Background

Femoral neck fractures in children are uncommon, making up little more than 1% of all paediatric fractures. It's not apparent which type of internal fixation-closed or open-is preferable in these situations when it comes to therapeutic options. When treating children with displaced femoral neck fractures, serious problems can arise.

Methods

Five databases were examined: Medline Plus, PubMed, Scopus, Science Direct, and Web of Science. The outcomes that were relevant for the meta-analysis were non-union, coxa vara, and avascular necrosis. Using the RevMan file, we extracted the data and carried out the analysis (Review Manager Version 5.3).

Results

294 patients had ORIF procedures and 266 patients had CRIF procedures in the included trials. Regarding the outcome of avascular necrosis, we discovered that there was no statistically significant difference between the two groups (RR = 0.84, [95% confidence range (CI) = 0.60, 1.18], P = 0.32). There was homogeneity in the data (P = 0.22, I2 = 27%). When it came to coxa vara, there was no statistically significant difference between the two groups (RR = 0.69, [95% CI = 0.30, 1.58], P = 0.38). There was homogeneity in the data (P = 0.22, I2 = 27%). Regarding non-union, the similar outcome was seen (RR = 0.45, [95% CI = 0.16, 1.14], P = 0.12). There was homogeneity in the data (P = 0.49, I2 = 0%).

Conclusion

Regarding reducing the risk of non-union, coxa vara, and avascular necrosis, we did not find any difference between CRIF and ORIF. To validate this outcome, however, additional research on the various variables (fracture type, age, displacement, fixation technique, and duration of surgery) is required. Sorting patients based on the kind of fracture will ensure that the right approach is used for each type.

Open reduction versus closed reduction in internal fixation of displaced femoral neck fracture in children: a systematic review and meta-analysis

BACKGROUND

The quality of reduction is an important factor affecting clinical outcomes for displaced femoral neck fractures (FNFs). However, concerns remain about the invasiveness of open reduction and internal fixation (ORIF) as compared to that of closed reduction and internal fixation (CRIF), and the choice between ORIF and CRIF as an optimal treatment strategy for displaced pediatric FNF remains controversial.

MATERIALS AND METHODS

MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published up to December 22, 2022, that compared ORIF and CRIF techniques for treating FNF in children. Pooled analysis identified differences in surgical outcomes between ORIF and CRIF, especially regarding postoperative complications, such as osteonecrosis of the femoral head (ONFH), nonunion, coxa vara deformity, leg-length discrepancy LLD, and premature physeal closure (PPC).

RESULTS

We included 15 studies with 635 pediatric FNF cases in our review. Of these, 324 and 311 were treated with ORIF and CRIF, respectively. The pooled analysis revealed that no significant differences existed between each reduction technique for ONFH (odds ratio [OR] = 0.89; 95% confidence interval [CI] 0.51-1.56; P = 0.69), nonunion (OR = 0.51; 95% CI 0.18-1.47; P = 0.21), coxa vara deformity (OR = 0.58; 95% CI 0.20-1.72; P = 0.33), LLD (OR = 0.57; 95% CI 0.18-1.82; P = 0.35), and PPC (OR = 0.72; 95% CI 0.11-4.92; P = 0.74).

CONCLUSIONS

Despite concerns about the invasiveness of ORIF, no differences in complications exist between ORIF and CRIF after FNF in children. Therefore, we believe that ORIF should be performed in FNF when the fracture is irreducible by closed manner.

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.

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.

Fractures of the Proximal Femur in Childhood: A Review

BACKGROUND

Femoral neck fractures in children are rare injuries, occurring due to high-energy trauma. Due to the unique anatomy and blood supply of the proximal femur in growing children, these fractures are notorious for high rates of complications despite appropriate management. Classification of these fractures is according to the Delbet system, which not only guides management but also gives prognostic clues. Multiple fixation methods have been described and there is no consensus on what constitutes the best treatment. Osteonecrosis, non-union, coxa vara and premature physeal arrest are the most frequent complications.

PURPOSE

To review the current knowledge, discuss controversial aspects, and provide suggestions for future research.

METHODS

We have reviewed the literature on paediatric proximal femur fractures and have provided an evidence-based guide to the diagnosis and management of these injuries. Common complications have been elaborated and options for their prevention and/or management discussed.

CONCLUSION

There is universal agreement that anatomic reduction and stable internal fixation, supplemented by spica immobilization in younger children, are essential to obtain good outcomes. The role of capsular decompression, choice and configuration of implant, and appropriate timing of surgery are aspects that continue to be debated. Multicenter prospective studies are necessary to standardize treatment of these challenging injuries.

Hip fractures in children and adolescents

BACKGROUND

Femoral neck fractures account for <1% of the fractures in children, and are produced by high energy trauma. The most commonly accepted treatment for such fractures is gentle manual anatomical reduction and internal fixation, yielding a healing rate between 80% and 90%.

SOURCES OF DATA

Electronic search through major web databases (Medline, Cochrane and Google Scholar). All types of article were eligible for inclusion, except for reviews, systematic reviews, meta-analyses and case reports. The methodological quality of the studies was assessed using the Methodological Index for NOn-Randomized Studies (MINORS).

AREAS OF AGREEMENT

Both open reduction and internal fixation (ORIF) and closed reduction and internal fixation (CRIF) can be used to manage hip fractures in paediatric patients. ORIF is more accurate in reducing and fixing the fracture, with better clinical and functional outcomes, and lower complication rate. Delayed fixation decreases the rate of acceptable outcome and increases the rate of complications.

AREAS OF CONTROVERSY

The methodological quality of the included studies is average-low, and the published evidence is not of sufficient quality to allow to draw final conclusion on the topic.

GROWING POINTS

Good results were reported for both ORIF and CRIF techniques, but are not supported by scientific evidence of adequate quality. More and better studies, including randomized trials, should be carried out to provide more scientifically evidence based conclusions.

Delayed treatment of femoral neck fractures in 58 children: open reduction internal fixation versus closed reduction internal fixation

The best treatment plan for femoral neck fractures in children in whom treatment is delayed by more than 24 h is unclear because of the limited number of such cases reported. This study compares the outcomes of closed and open reduction performed 24 h after the injury was sustained. We retrospectively reviewed 58 cases (40 males, 18 females) of femoral neck fractures reset after more than a 24-h delay at our hospital (May 2005 to May 2014). According to Delbet's classification, there were 30 type II fractures (51.7%), 21 type III fractures (36.2%), and seven type IV fractures (12.1%). A total of 21 patients underwent closed reduction and internal fixation; the remaining patients underwent open reduction and internal fixation. The follow-up period was 17-61 months (average, 35.1 months). The results were classified according to Ratliff's criteria. With the exception of one case of bone nonunion (closed reduction group), the fracture was healed in the remaining cases. The average healing time was 10.82 weeks (9-13 weeks). The incidence of avascular necrosis was significantly lower in the open reduction group. Further, the percentage of results classified as 'fine' according to Ratliff's criteria was significantly higher in the open reduction group than in the closed reduction group. Coxa vara occurred in three patients in the closed reduction group, but it did not occur in any of the patients in the open reduction group. The incidence of avascular necrosis was significantly lower in the patients who achieved anatomical reduction than in the patients who only achieved acceptable reduction. Finally, the results in the anatomical reduction group were obviously better than those in the acceptable reduction group. Open reduction with internal fixation yielded better outcomes than closed reduction in this group of children with displaced femoral neck fractures who were treated more than 24 h after the injury. This may be related to the better reduction quality in the open reduction group.

LEVEL OF EVIDENCE

Therapeutic studies: investigating the results of treatment, Level III.

Open Reduction of Pediatric Femoral Neck Fractures Reduces Osteonecrosis Risk

Pediatric femoral neck fractures are rare injuries that are associated with a high risk of osteonecrosis of the femoral head. This study compared pediatric patients with fully displaced femoral neck fractures treated with either open reduction and internal fixation (ORIF) or closed reduction and internal fixation (CRIF). After institutional review board approval was obtained, the authors identified 53 patients who were treated for femoral neck fracture between 2003 and 2012. Inclusion criteria were as follows: (1) diagnosis of a fully displaced femoral neck fracture with no anatomic cortical contact; (2) age of at least 4 years; and (3) clinical/radiographic follow-up of at least 1 year. Medical records and radiographs were retrospectively reviewed. Excluded from the study were 16 patients who had fractures that were not fully displaced, 4 who were outside of the eligible age range, 1 who had insufficient radiographs, and 10 who had insufficient follow-up. Of the 22 patients included, 6 were treated with ORIF and 16 were treated with CRIF. Treatment groups were compared with Fisher's exact test for categorical outcome data and the Wilcoxon rank-sum test for continuous variables. There was a significantly (P=.051) greater occurrence of osteonecrosis after CRIF (50%) than after ORIF (0%). Further, patients who underwent ORIF had a higher (P=.009) quality of reduction, a higher (P=.046) rate of anatomic union, and fewer (P=.009) complications than those who underwent CRIF. Major complications occurred in significantly fewer (P=.015) hips after ORIF than after CRIF. No significant difference (P=.477) was seen between groups, according to the Ratliff assessment of final results. Fully displaced pediatric femoral neck fractures treated with ORIF had a significantly higher quality of reduction, with fewer complications, including osteonecrosis, than those treated with CRIF.

Factors affecting the outcome of fractures of the femoral neck in children and adolescents: a systematic review

Fractures of the femoral neck in children are rare, high-energy injuries with high complication rates. Their treatment has become more interventional but evidence of the efficacy of such measures is limited. We performed a systematic review of studies examining different types of treatment and their outcomes, including avascular necrosis (AVN), nonunion, coxa vara, premature physeal closure (PPC), and Ratliff's clinical criteria. A total of 30 studies were included, comprising 935 patients. Operative treatment and open reduction were associated with higher rates of AVN. Delbet types I and II fractures were most likely to undergo open reduction and internal fixation. Coxa vara was reduced in the operative group, whereas nonunion and PPC were not related to surgical intervention. Nonunion and coxa vara were unaffected by the method of reduction. Capsular decompression had no effect on AVN. Although surgery allows a more anatomical union, it is uncertain whether operative treatment or the type of reduction affects the rate of AVN, nonunion or PPC, because more severe fractures were operated upon more frequently. A delay in treatment beyond 24 hours was associated with a higher incidence of AVN.

Bilateral femoral neck fracture in a child: a 17-year follow-up

A long-term follow-up of bilateral femoral neck fracture is presented. The patient sustained the injury in a road accident at the age of five. Both fractures were Delbet type III. Three days after the injury, open reduction and internal fixation were performed. A hip spica cast was applied for 8 weeks. Follow-up radiographs show uneventful healing, with no avascular necrosis of the femoral head. The initial shortening of the right proximal femur persisted. The left femur shows extensive remodeling of the femoral head toward valgus. The patient is painless and currently does some sports.

Displaced femoral neck fractures in children: are complications predictable?

INTRODUCTION

Serious complications can occur in the management of displaced femoral neck fractures in children. Are there ways to anticipate this risk and better define eventual contributing factors?

PATIENTS AND METHODS

Twenty-one children (14 boys and 7 girls) were treated between 1999 and 2006 for displaced femoral neck fractures. Nine type II, 10 type III and two type IV fractures were observed according to the Delbet's classification. Anatomical open reduction was performed in 13 patients and closed reduction in eight patients. At a mean follow-up of 26.4 months, the outcome was assessed according to the Ratliff criteria. Postoperative complications were analysed according to the age, fracture type, time-to-surgery and open or closed reduction.

RESULTS

The mean age was 12.1 years. The final outcome was defined as good in 14 patients(66.66%), fair in one patient (4.76%) and poor in six patients (28.58%). Complications occurred in seven patients (33.33%), avascular necrosis (AVN) of the femoral head being the most frequent one (28.58%). In all cases, necrosis was observed in children older than 12 years (p < 0.05) and when time-to-surgery exceeded 48 h (p < 0.05). Necrosis occurred in 44.44% of type II fractures and in 20% of type III fractures (p > 0.05). Only one materialised after closed reduction (p < 0.05).

DISCUSSION

Various factors may contribute to the development of complications in children with femoral neck fractures. Our study supports the hypothesis that older age, late surgery and open reduction are definite predictors of avascular necrosis occurrence.

LEVEL OF EVIDENCE

Retrospective study, level IV.

Traumatic transepiphyseal separation of the upper femoral epiphysis following seizures in a 5-month-old child: a case report

INTRODUCTION

Traumatic transepiphyseal separation of the upper femoral epiphysis is a rare lesion of the hip in children.

CASE REPORT

We report a case of conservative treatment of transepiphyseal separation of the upper femoral epiphysis following tonic/clonic seizures in a 5-month-old child. Magnetic resonance imaging confirmed the diagnosis The fracture was maintained with hip spica cast for 6 weeks. At the age of 2, complete healing of the lesion including femoral neck remodeling was noted on frontal and lateral radiographs. There was no radiological evidence of AVN or premature closure of the physis. He continues to be followed up.

DISCUSSION

Because of the remodeling potential in young children, we assume not to perform additional reduction procedures in such traumatic lesions.

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

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.