Ipsilateral femoral neck and shaft fracture in children: a report of two cases and a literature review

Incidence of Ipsilateral Femoral Neck and Shaft Fractures in Pediatric and Adolescent Patients

OBJECTIVES

To identify the incidence, patient characteristics, and effectiveness of radiographic screening methods for detecting ipsilateral femoral neck and shaft fractures in pediatric and adolescent trauma patients.

METHODS

DESIGN

Retrospective cohort study.

SETTING

This study was conducted at a tertiary pediatric trauma hospital.

PATIENT SELECTION CRITERIA

Patients younger than 18 years treated for a femoral shaft fracture between 2004 and 2018 were reviewed. Pathologic (metabolic bone disease or bone lesion), periprosthetic, and penetrating traumatic femoral shaft fractures were excluded.

OUTCOME MEASUREMENTS AND COMPARISONS

Patient demographics, mechanisms of injury, treatment methods, and associated injuries were analyzed. Pretreatment x-rays and computed tomography (CT) scans were reviewed for the identification of ipsilateral femoral neck and shaft fractures.

RESULTS

Among the 840 pediatric patients included in this study, 4 patients (0.5%) sustained ipsilateral femoral neck and shaft fractures. All the femoral neck fractures were observed in adolescents (aged 13-17 years) and involved in high-energy traumas. In adolescents involved in high-energy trauma, the incidence increased to 1.7%. Pretreatment sensitivity of both x-rays and CT scans was only 50% for the detection of femoral neck fractures.

CONCLUSIONS

This study reveals that ipsilateral femoral neck and shaft fractures in pediatric patients are rare, occurring in adolescents involved in high-energy trauma. The findings suggest the need for a selective, rather than routine, use of CT scans based on the patient's age and the mechanism of injury. The use of alternative imaging methods such as magnetic resonance imaging should be considered to balance diagnostic accuracy while minimizing radiation exposure.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Do All Pediatric Femoral Shaft Fractures Need a Computed Tomography Scan of the Ipsilateral Femoral Neck? Calculating the Incidence of Concomitant Femoral Neck and Shaft Fractures

BACKGROUND

In adults, the incidence of ipsilateral femoral neck fractures in the setting of femoral shaft fractures is reported to be as high as 9%; however, scant literature exists on the same clinical scenario in pediatric/adolescent populations. Therefore, the purpose of this study was to investigate the incidence of ipsilateral femoral neck fracture in the setting of femoral shaft fractures in children and adolescents treated in pediatric hospitals across the United States.

METHODS

The Pediatric Health Information System database was queried for patients aged 18 years or younger who were treated for a femoral neck, femoral shaft, and pertrochanteric femur fractures through an emergency department, inpatient, ambulatory surgery, or observation visit. Patients were identified using ICD-9 and ICD-10 diagnosis codes. Data from 49 pediatric hospitals between the years 2002 and 2020 were included. Incidence was calculated as the number of cases including the event divided by the total number of cases.

RESULTS

A total of 90,146 records were identified from a cohort of 55,733,855 (0.16%). Distal femur fractures, pathologic fractures, and periprosthetic fractures were excluded, resulting in 65,651 unique cases. Of the 65,651 cases, 7104 (11%) were identified as isolated neck fractures. The combined incidence of femoral neck or pertrochanteric femur fractures in the setting of a femoral shaft fracture was 82.3 per 10,000 cases (0.82%). Only 283 cases of concomitant femoral neck and shaft fractures were found among 55,169 femoral shaft fractures (0.5%).

CONCLUSIONS

The incidence of ipsilateral femoral neck or pertrochanteric femur fractures in the setting of a femoral shaft fracture is 82.3 per 10,000 patients (0.82%) based on data from Pediatric Health Information System-participating institutions. The incidence of femoral neck/pertrochanteric femur fractures and femoral shaft fractures in children and adolescents is more than 10 times lower than reported for adults; therefore, the routine use of advanced diagnostic imaging in pediatric patients with femoral shaft fractures should be considered cautiously.

LEVEL OF EVIDENCE

Level IV; cross-sectional analysis.

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.

Dilemma for Fracture Fixation of Paediatric Ipsilateral Neck with Shaft Femur Fracture

BACKGROUND

Ipsilateral femoral neck with shaft fracture (IFNSF) in the paediatric population is a rare injury. This high-impact trauma is often associated with other orthopaedic and systemic injuries. Prognosis is usually guarded as both these osseous injuries are serious and exist together. We report two such patients of IFNSF.

METHODS

Two children with IFNSF were admitted at our hospital in 2018. The first patient had an associated head injury, while in the second patient, the shaft femur fracture was open. We report on the treatment and results in these two patients. Both the patients were serially assessed and followed 2 years after the injury.

RESULTS

Union was achieved in neck and shaft femur fractures in both the patients by 3 months. Complications like avascular necrosis (AVN) of the femoral head, coxa vara, non-union or malunion of fractures, limb length discrepancy, knee and hip stiffness were not seen in either of the patients.

CONCLUSION

IFNSF is a rare injury pattern seen in children, usually associated with concomitant orthopedic and other systemic injuries. Early operative stabilization is the preferred modality of treatment. For an undisplaced neck fracture, a provisional temporary fixation of a relatively less displaced neck fracture, definitively stabilizing the shaft fracture, and thereby returning to fix neck fracture is advocated. For displaced neck fractures, a direct open reduction is advocated. Anatomical fixation with separate implants and a relatively longer immobilization can provide the best-expected results. Long-term follow-up is needed to foresee any complications.

LEVEL OF EVIDENCE

V (case series). Therapeutic.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-020-00315-z.

Advantages and limitations of intramedullary nailing for the surgical treatment of ipsilateral intertrochanteric and femoral shaft fractures: a retrospective comparative study based on propensity score matching

INTRODUCTION

The aim of the present study was to introduce surgical technique using long PFNA for the treatment of ipsilateral intertrochanteric and femoral shaft fractures, and evaluate the characteristics of this fracture by comparing its surgical outcomes with those of isolated intertrochanteric and femoral shaft fractures.

MATERIALS AND METHODS

Between March 2013 and December 2018, 38 patients with ipsilateral intertrochanteric and femoral shaft fracture were identified at two institutions. Twenty-eight patients with ipsilateral intertrochanteric and femoral shaft fractures were enrolled in the present study. After propensity score matching, fifty-six patients with isolated intertrochanteric (group B) and femoral shaft (group C) fractures were finally enrolled in the present study for 1:2 matching to compare surgical outcomes to that of ipsilateral intertrochanteric and femoral shaft fractures (Group A).

RESULTS

All 28 patients achieved union of intertrochanteric fractures, while two experienced non-union of femoral shaft fractures. The union time of intertrochanteric fractures in group A was significantly shorter than that in group B. The union time of femoral shaft fractures in group A was significantly longer than that in group C.

CONCLUSIONS

The surgical treatment of ipsilateral intertrochanteric and femoral shaft fractures using long PFNA was advantageous as it allowed both fractures on the same femur to be fixed in one go and showed good surgical outcomes. However, fixation of femoral shaft fractures might be insufficient depending on the fracture level and configuration, and can be a cause of hypertrophic non-union.

Treatment comparison of femoral shaft with femoral neck fracture: a meta-analysis

Background

To compare the efficacy and complications between reconstruction nail and hollow screw+plate in patients with femoral shaft and femoral neck fracture.

Methods

The full text of studies on clinical efficacy involving reconstruction nail and hollow screw+plate was retrieved from multiple databases. Review Manager 5.0 was adopted for meta-analysis, sensitivity analysis, and bias analysis. The meta-analysis was conducted with respect to the operation time, blood loss, healing time of the femoral shaft, healing time of the femoral neck, and complications. Finally, 10 studies met the eligibility criteria, including 991 patients.

Results

The meta-analysis suggested better characteristics for the reconstruction nail compared with the hollow screw+plate regarding operation time (OR = − 82.41, 95% CI [− 91.72, − 73.10], P < 0.00001; P for heterogeneity < 0.00001, I² = 98%), blood loss (OR = − 388.01, 95% CI [− 422.95, − 353.06], P < 0.00001; P for heterogeneity < 0.00001, I² = 99%), healing time of femoral shaft (MD = − 3.89, 95% CI [− 4.74, − 3.05], P < 0.00001; P for heterogeneity < 0.00001, I² = 99%), healing time of femoral neck (MD = − 4.04, 95% CI [− 4.33, − 3.75], P < 0.00001; P for heterogeneity = 0.008, I² = 60%), and complications (OR = 0.47, 95% CI [0.31, 0.73], P = 0.0006; P for heterogeneity = 1.00, I² = 0%).

Conclusion

This meta-analysis shows that a reconstruction nail is a more efficient and safer treatment than a hollow screw+plate for patients with femoral shaft and femoral neck fracture.

Diagnosis and Management of Ipsilateral Femoral Neck and Shaft Fractures

Ipsilateral femoral neck and shaft fractures typically occur as a result of high-energy trauma in young adults. Up to 9% of femoral shaft fractures will have an associated femoral neck fracture. Awareness of this association and the use of a protocolized approach to diagnosis and management can help prevent missed injuries and the associated complications of displacement, nonunion, and osteonecrosis. The femoral neck fracture is often vertically oriented and either nondisplaced or minimally displaced, and thus, these fractures are frequently missed in the initial evaluation. Fixation of these combined injury patterns is challenging, and multiple treatment options exist. Treatment goals should include anatomic reduction and adequate fixation of the femoral neck fracture, as well as restoration of the length, alignment, and rotation of the femoral shaft fracture.