Fractures of the hip in children

Analysis of influential factors on surgical outcomes in pediatric femur neck fractures: a single-institution retrospective study

AIM

This retrospective study aimed to evaluate surgical outcomes and identify influential factors in pediatric femoral neck fractures.

MATERIALS AND METHODS

A total of 25 hips from 23 pediatric patients who underwent surgical intervention for femoral neck fractures were included. Data encompassing patient demographics, fracture types, surgical techniques, complications, and follow-up outcomes were analyzed retrospectively. Factors such as fracture displacement, timing of surgery, fixation methods, and reduction quality were assessed concerning postoperative complications.

RESULTS

Falling from a height accounted for 48% of the trauma mechanisms, and avascular necrosis (AVN) was the most prevalent complication (4 hips). Although fracture displacement, bad reduction quality, and delayed surgery were more common among complicated cases, statistical significance was not attained. The study noted an association between presence of avascular necrosis and worse clinical results(rho: 0.428, p: 0.05, CI: 95%).

CONCLUSION

Surgical treatment yielded favorable clinical outcomes; however, limitations due to the study's retrospective design, limited sample size, and single-center approach underscore the necessity for larger multicenter studies. Our findings emphasize the need for comprehensive investigations to better understand and manage pediatric femoral neck fractures, especially regarding factors influencing AVN and long-term outcomes.

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.

The clinical features, management options and complications of paediatric femoral fractures

This article discusses the incidence, applied anatomy and classification of paediatric femoral fractures based on critical appraisal of the available evidence. The aim is to identify techniques that are relevant to contemporary practice whilst excluding the technical details of individual procedures that are beyond the scope of this review. Injuries of the proximal, diaphyseal and distal segments are considered individually as there are considerations that are specific to each anatomical site. Femoral neck fractures are rare injuries and require prompt anatomical reduction and stable fixation to minimise the potentially devastating consequences of avascular necrosis. Diaphyseal fractures are relatively common, and there is a spectrum of management options that depend on patient age and size. Distal femoral fractures often involve the physis, which contributes up to 70% of femoral length. Growth arrest is common consequence of fractures in this region, resulting in angular and length-related deformity. Long-term surveillance is recommended to identify deformity in evolution and provide an opportunity for early intervention. Deliberate injury should be considered in all fractures, particularly distal femoral physeal injuries and fractures in the non-walking child.

Current controversies in management of fracture neck femur in children: A review

Paediatric femur neck fracture is an uncommon injury and is known for high rate of complications. This in turn, can have significant impact on development of hip and overall function of the child. Controversy prevails in many areas of management and it still remains a difficult injury to manage. Through this paper, an attempt has been made to summarize the current concepts in management and suggest current recommendations regarding the controversies so that these injuries can be managed judiciously. A systematic review was done as per PRISMA guidelines using pre-defined inclusion and exclusion criteria. 18 studies with better scientific evidence after quality assessment were included in the systematic review. Current trends and Controversial issues in management were then identified and discussed. It was observed that existing literature is inconclusive regarding several aspects of management of this injury with no clear guideline available. However, certain recommendations useful for decision making could be made. These injuries should be managed aggressively with operative fixation at the earliest and one should not hesitate to open reduce if acceptable alignment is not obtained after one or two gentle closed manipulations. Choice of implant and their configuration in neck can vary depending on age and weight of patient, type of injury and surgeon's preference. Initial fracture displacement could be considered to be most predictive for development of osteonecrosis of the femoral head, whereas, role of surgical decompression, type of fixation and timing of surgery is still debatable. Functional outcome is primarily affected by osteonecrosis of the femoral head, nonunion and severe coxa vara, whereas mild coxa vara, shortening, and premature closure of physis when considered alone, don't have significant influence on functional outcome in short term. Treatment of fracture neck femur in children is still controversial in many aspects and needs further research. It should be understood that complications can occur regardless of the method of treatment and might reveal their full impact many years after injury. Hence, a guarded prognosis should be explained to the parents and care-givers at the time of injury.

[Progress of hip fracture treatment in children]

Objective

To review the progress of hip fracture treatment in children.

Methods

Literature about the hip fracture treatment in children was extensively reviewed and summarized in terms of anatomy and blood supply, fracture classification, surgical treatment principles, and complications.

Results

The anatomical structure of children's hips and the characteristics of peripheral blood supply constantly change with age. Delbet classification is the most classic classification of hip fracture in children. Children's age and Delbet classification have significant effects on surgical treatment strategies and post-fracture complications. The timing of surgical treatment, accurate anatomical reduction, and appropriate internal fixation can effectively improve the prognosis and reduce the incidence of complications. Common complications include osteonecrosis of the femoral head, coxa vara, premature physeal closure, and nonunion.

Conclusion

There are still some controversies on the treatment concept and internal fixation choice for children's hip fracture. So it is necessary to further study the anatomy and blood supply characteristics of children's hip, improve the selection and application skills of internal fixation devices, so as to avoid serious complications.

Review of 16 cases of aneurysmal bone cyst in the proximal femur treated by extended curettage and cryosurgery with reconstruction using autogenous nonvascularized fibula graft

BACKGROUND

Aneurysmal bone cyst (ABC) is an aggressive benign lesion that may sometimes be difficult to treat. Lesions that occur in the proximal femur require to be addressed aggressively because of the high rate of local recurrence and the risk of fracture. Few articles report the experience of management of ABC in the proximal femur. This location presents a surgical challenge due to its anatomical and biomechanical peculiarity.

METHODS

We retrospectively reviewed 16 cases with ABC in the proximal femur that were treated in our institution between 2005 and 2014, utilizing extended curettage and liquid nitrogen as adjuvant therapy and reconstruction using nonvascularized autogenous fibular strut graft. The mean follow-up period was 50.5 months. Five cases presented as recurrent cases, while four cases presented with pathological fractures.

RESULTS

The functional score ranged from 70 to 90 on modified Musculoskeletal Tumor Society score with a mean score of 81.25, which is considered to be excellent function. Time for graft incorporation ranged from 10 to 12 weeks. One case got local recurrence, and one case got early surgical site infection.

CONCLUSIONS

Extended curettage and cryotherapy represent a recommended approach for management of ABC in the proximal femur with favorable results.

Fragility fractures and reversible osteopaenia due to chronic hyponatraemia in an adolescent male

Fragility fractures are common in older adults and rare in children. Recent studies have demonstrated that hyponatraemia is a novel risk factor for the development of osteoporosis and hip fractures in older people. Animal studies suggest that hyponatraemia can lead to decreased bone mineral density by stimulating osteoclastic activity in order to mobilise sodium from the bone. Reported is a 16-year-old man with intractable epilepsy and an 11-year history of chronic hyponatraemia (126-135 mEq/L) due to valproic acid induced syndrome of inappropriate antidiuresis who sustained low-impact fragility fractures and had evidence of osteopaenia on both X-ray and dual energy X-ray absorptiometry (DEXA). Hyponatraemia resolved following the discontinuation of valproic acid and bone mineral density normalised on a repeat DEXA 19 months later. This case provides evidence supporting the contention that chronic hyponatraemia contributes to osteopaenia and fragility fractures and that the bone abnormalities are potentially reversible following the correction of hyponatraemia.

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.

Neglected femoral neck fracture in patient with seizure: a case of a delayed fixation of type 1A fracture in 11-month-old infant

Fractures of the hip are rare injuries in children, accounting for less than 1 % of all pediatric fractures. Compared with other pediatric skeletal injuries, hip fractures are associated with high complication rates and poor outcomes, most commonly osteonecrosis, as well as non-union and malunion. Although significant trauma is the most common reason of the separation of upper femoral epiphysis, furthermore some cases were reported after seizures. To our knowledge, there is no previous publication in the literature that reports the results of delayed reduction and fixation of transepiphyseal separation of the proximal femoral epiphysis. We report a case of delayed open reduction and internal fixation of Delbet type 1A femoral neck fracture following seizures in an 11-month-old male child.

CORRELATION BETWEEN AVASCULAR NECROSIS AND EARLY STABILIZATION OF PROXIMAL FEMORAL FRACTURES IN CHILDHOOD

OBJECTIVE

We developed this study with the aim of evaluating the results from treating patients with proximal femoral fractures, in a series of cases. We sought to observe the influence of the most prevalent complications on the final results after a minimum follow-up of two years. We especially considered the relationship between establishment of avascular necrosis and the time between the accident and the therapeutic intervention.

METHOD

We retrospectively studied proximal extremity fractures of the femur in 29 patients under 14 years of age between 1988 and 2007. We analyzed the following variables: sex, age, mechanism of injury, fracture classification (Delbet), treatment administered, complications (pseudarthrosis, varus deformity, leg length discrepancy and avascular necrosis), duration of surgery and results (Ratliff). We carried out individual descriptive analysis on each variable. The tests were used in accordance with the premise that normality applied. For the evaluation, we used Fisher's exact test.

RESULTS

Five patients (17.2%) had avascular necrosis, and three of them (60.0%) were over 10 years of age. 73.3% of the patients treated within the first 24 hours showed good results. The most common cause of fractures was traffic accidents (44.8%). The best results were observed among patients who were treated surgically. 41.4% developed some type of complication.

CONCLUSIONS

Among the 29 patients treated, 58.6% had good, 27.6% had regular and 13.8% had poor results, according to the Ratliff criteria. When conservative treatment was applied, only 17.0% had good results, while 69.3% had good results from surgical intervention. Likewise, 73.3% of the results were good results when surgery was performed within the first 24 hours and only 42.8% of the results were good among patients who underwent surgery after this period. Patients operated within the first 24 hours developed necrosis of the femoral head in 13.3% of cases, while 21.4% of those operated after this period developed this complication.

Hip fractures in children

Hip fractures account for <1% of all pediatric fractures. Most are caused by high-energy mechanisms, but pathologic hip fractures also occur, usually from low-energy trauma. Complications occur at a high rate because the vascular and osseous anatomy of the child's proximal femur is vulnerable to injury. Surgical options vary based on the child's age, Delbet classification type, and degree of displacement. Anatomic reduction and surgical stabilization are indicated for most displaced hip fractures. Other options include smooth-wire or screw fixation, often supplemented by spica cast immobilization in younger children, or compression screw and side plate fixation. Achievement of fracture stability is more important than preservation of the proximal femoral physis. Capsular decompression after reduction and fixation may diminish the risk of osteonecrosis. Osteonecrosis, coxa vara, premature physeal closure of the proximal femur, and nonunion are complications that account for poor outcomes.

Posttraumatic avascular necrosis of the femoral head in teenagers treated by a modified transtrochanteric rotational osteotomy: a report of three cases

Posttraumatic necrosis (AVN) of the femoral head in children is the most serious complication of femoral neck fractures in children, although it can also be seen after other injuries to the hip such as dislocations. There are only a few reports on the treatment for posttraumatic AVN, and options for treating this complication in the pediatric population are limited. We report our experience in managing 3 cases of posttraumatic avascular necrosis of the femoral head in teenagers with a modified transtrochanteric rotational osteotomy.