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Taşcı M, Başak F, Kemah B, Söylemez MS. Analysis of influential factors on surgical outcomes in pediatric femur neck fractures: a single-institution retrospective study. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02584-x. [PMID: 38951157 DOI: 10.1007/s00068-024-02584-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 06/14/2024] [Indexed: 07/03/2024]
Abstract
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.
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Affiliation(s)
- Murat Taşcı
- Department of Orthopaedics and Traumatology, Umraniye Training and Research Hospital, Istanbul, Türkiye.
| | - Furkan Başak
- Department of Orthopaedics and Traumatology, Umraniye Training and Research Hospital, Istanbul, Türkiye
| | - Bahattin Kemah
- Department of Orthopaedics and Traumatology, Umraniye Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Salih Söylemez
- Department of Orthopaedics and Traumatology, Umraniye Training and Research Hospital, Istanbul, Türkiye
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Mishra PK, Jain S, Nadeem M. Three-Year Experience and Outcomes of Near-Early Internal Fixation for Femoral Neck Fractures in Pediatric Trauma Patients: A Retrospective Study. Cureus 2023; 15:e40049. [PMID: 37425594 PMCID: PMC10324986 DOI: 10.7759/cureus.40049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2023] [Indexed: 07/11/2023] Open
Abstract
Background The fractured neck of the femur in children is commonly caused by high-energy trauma, and despite its low incidence, complications are more frequent. Delayed presentation is not unusual in developing countries. The interval between injury and surgery is thought to be a critical factor in determining outcomes. This study aims to evaluate the effectiveness of "near early" internal fixation (24-72 hours) for fractured neck of the femur in children. Methods This is a retrospective observational study that analyzed complete case records from a period of seven years. Cases were classified according to the Delbet classification and outcomes were assessed using the Ratliff criteria with a minimum follow-up of three years. Results The study included 24 male and 11 female patients, with an average age of 11.28 years. The most common cause of injury was road traffic accidents. The fracture distribution in the study population was as follows: Delbet type II in 18 patients, Delbet type III in 10 patients, and Delbet type IV in seven patients. In our study, all patients underwent near-early fixation, meaning their fractures were fixed within 24-72 hours of injury. The average time for the clinical-radiological union was 8 weeks, and the most common complication was premature physeal fusion, followed by osteonecrosis. Conclusion In developing countries, where patients often experience delayed referrals and lack of awareness, near-early fixation (24-72 hours) of a fractured neck of the femur in children is a crucial option that holds significant value.
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Affiliation(s)
- Pankaj K Mishra
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Siddharth Jain
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, IND
| | - Mohammed Nadeem
- Department of Orthopaedics, Gandhi Medical College, Bhopal, IND
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Chandankere V, Shah H. Controversies in the management of pediatric neck femur fractures- a systematic review. J Orthop 2021; 27:92-102. [PMID: 34588744 DOI: 10.1016/j.jor.2021.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 07/12/2021] [Accepted: 08/29/2021] [Indexed: 10/20/2022] Open
Abstract
Purpose To review controversies systematically in the management of pediatric neck femur fracture from the literature and to develop consensus for the optimum management. Methods Authors searched literature by using keywords of pediatric neck femur fracture, proximal femur fracture, complications, management by following PRISMA guidelines. A common dilemma was listed. Results Age, mechanism of injury, fracture type, presentation, treatment method, implant, and nature of complications were compared. Inference from recent literature was extracted for optimum management. Conclusion Immediate anatomical reduction with stable fixation must be accomplished. Complications continue to happen despite the best efforts and a longer follow-up is important.
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Affiliation(s)
| | - Hitesh Shah
- Pediatric Orthopaedics Services, Department of Orthopaedics, KMC, Manipal, Manipal Academy of Higher Education, Manipal, 576104, India
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The clinical features, management options and complications of paediatric femoral fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:883-892. [PMID: 33839930 PMCID: PMC8233277 DOI: 10.1007/s00590-021-02933-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/08/2021] [Indexed: 10/27/2022]
Abstract
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.
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Current controversies in management of fracture neck femur in children: A review. J Clin Orthop Trauma 2020; 11:S799-S806. [PMID: 32999559 PMCID: PMC7503071 DOI: 10.1016/j.jcot.2020.05.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 11/21/2022] Open
Abstract
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.
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Abstract
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.
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Fassihi SC, Mortman R, Shalkevich J, Lee D, Stoll WT, Thakkar S. Total Hip Arthroplasty for the Sequelae of Femoral Neck Fractures in the Pediatric Patient. Arthroplast Today 2020; 6:296-304. [PMID: 32509942 PMCID: PMC7264979 DOI: 10.1016/j.artd.2020.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/10/2020] [Accepted: 04/15/2020] [Indexed: 11/26/2022] Open
Abstract
Although rare, total hip arthroplasty (THA) may be indicated in pediatric patients with degenerative changes of the hip joint after previous trauma. To illustrate management principles in this patient population, this study describes the case of a 15-year-old female who sustained bilateral femoral neck fractures after a generalized tonic-clonic seizure, an atypical, low-energy mechanism for this injury. These fractures were not diagnosed until 14 weeks after the seizure episode, at which point they had progressed to nonunion on the left side, malunion on the right side, and degenerative hip joint changes were developing bilaterally. Bilateral THA was ultimately performed, and the patient had favorable outcomes at 1 year postoperatively. In determining the optimal management strategy for such patients, a multidisciplinary approach should be used, with input from the patient’s family, pediatrician, pediatric endocrinologist, pediatric orthopaedic surgeon, and adult reconstruction surgeon. From a surgical standpoint, this report highlights the importance of selecting the appropriate bearing surfaces, broaching technique, mode of implant fixation, and implant features when performing THA in the active pediatric patient.
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Affiliation(s)
- Safa C Fassihi
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
| | - Ryan Mortman
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
| | - Jacob Shalkevich
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
| | - Danny Lee
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
| | - William T Stoll
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
| | - Savyasachi Thakkar
- Department of Orthopaedic Surgery, Georgetown University MedStar Health, Washington, DC, USA
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Singh KA, Chandankere V, Shah H. Does the timing of treatment affect complications of pediatric femoral neck fractures? J Orthop 2020; 22:207-212. [PMID: 32425419 DOI: 10.1016/j.jor.2020.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/05/2020] [Accepted: 04/30/2020] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Kumar Amerendra Singh
- Department of Orthopaedics, Kasturba Hospital, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | | | - Hitesh Shah
- Department of Orthopaedics, Kasturba Hospital, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
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Yang H, Liu Y, Liu L. [Progress of hip fracture treatment in children]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:404-408. [PMID: 32174091 DOI: 10.7507/1002-1892.201907005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Hai Yang
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Yang Liu
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
| | - Lei Liu
- Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China
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Chen Y, Zhang X, Guo H, Liu N, Ren J, Lu C. Poor Outcomes of Children and Adolescents with Femoral Neck Fractures: A Meta-Analysis Based on Clinical Studies. Orthop Surg 2020; 12:639-644. [PMID: 32162445 PMCID: PMC7189036 DOI: 10.1111/os.12629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 01/08/2020] [Accepted: 01/14/2020] [Indexed: 02/03/2023] Open
Abstract
Objective To comprehensively assess the differences in outcome between open reduction and closed reduction for children and adolescents with femoral neck fractures. Methods Based on the predetermined strategies, eligible studies were obtained by searching Embase, the Cochrane Library, and PubMed databases (retrieval time: June 2018) and through manual retrieval for paper documents. The 95% confidence intervals (CI) and risk ratios (RR) were used as evaluation indexes. Moreover, the results of avascular necrosis, coxa vara, or non‐union were compared between open reduction and closed reduction under random or fixed effects models. After sensitivity analysis was carried out, publication bias was evaluated for the eligible studies using Egger's test. Results Six studies were included in our meta‐analysis. No significant heterogeneity was found among the included studies (P ≥ 0.05) and, thus, the fixed effects model was used for merging the effect sizes of avascular necrosis (RR [95% CI] = 0.50 [0.26, 0.98], P = 0.04), coxa vara (RR [95% CI] = 0.16 [0.04, 0.70], P = 0.01), and non‐union (RR [95% CI] = 0.22 [0.05, 0.93], P = 0.04). Sensitivity analysis suggested that the results of avascular necrosis were not stable (RR = 0.50, 95% CI = 0.25 1.17, P = 0.12), while those of coxa vara and non‐union were stable. There was no significant publication bias among the eligible studies (t = −0.70, P = 0.522). Conclusion Femoral neck fractures treated by open reduction had less adverse outcomes compared with those treated by closed reduction.
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Affiliation(s)
- Yingpu Chen
- Department of Orthopedics, Xi'an Hong Hui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Xiaojun Zhang
- Department of Orthopedics, People's Hospital of Tongchuan, Tongchuan, China
| | - Hao Guo
- Department of Orthopedics, Xi'an Hong Hui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Na Liu
- Department of Orthopedics, Xi'an Hong Hui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Jing Ren
- Department of Orthopedics, Xi'an Hong Hui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Chao Lu
- Department of Orthopedics, Xi'an Hong Hui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
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Initial displacement as a risk factor for avascular necrosis of the femoral head in pediatric femoral neck fractures: a review of one hundred eight cases. INTERNATIONAL ORTHOPAEDICS 2019; 44:129-139. [DOI: 10.1007/s00264-019-04429-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 10/01/2019] [Indexed: 10/25/2022]
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12
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Abstract
Pediatric proximal femur fractures are rare injuries resulting from high-energy trauma. The Delbet classification is used when describing these injuries, and associates fracture type to the development of avascular necrosis. Historically, casting was utilized in the treatment of these injuries, but high complication rates following this approach have changed the treatment modality to early and anatomic fixation. Complications associated with these injuries including avascular necrosis, non-union, coxa-vara, and premature physeal fusion. Achieving anatomic reduction and performing internal fixation within 24 h from time of injury has become the standard of care in the treatment of pediatric proximal femur fractures.
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Affiliation(s)
- Brian L Dial
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Robert K Lark
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Yaokreh JB, Odehouri-Koudou TH, Dieth GA, Tembely S, Kouame YGS, Kouame BD, Ouattara O. Management of femoral neck fractures in children: Experience of a short series in a developing country. Afr J Paediatr Surg 2018; 15:114-117. [PMID: 31290477 PMCID: PMC6615012 DOI: 10.4103/ajps.ajps_93_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Fractures of the femoral neck are rare injuries in children but can have many devastating complications. Their treatment is not standardized, but the objectives are early anatomic reduction to minimize the risk for complications. The aim of this study was to assess outcomes of a short series of femoral neck fractures managed in a resource-limited setting. MATERIALS AND METHODS The medical charts of 11 children who were managed in our institution for femoral neck fractures between January 2000 and December 2015 were assessed retrospectively. There were two cases (n = 2) of Delbet type I, 5 (n = 5) type II, and 4 (n = 4) type III fractures. Patients were treated either surgically by open reduction and internal fixation (n = 4) or conservatively by traction followed by spica cast (n = 7). Outcomes were assessed using Ratliff system. RESULTS Femoral neck fracture incidence was one case per year. Of the 11 patients, there were 7 boys and 4 girls, with a mean age 9.4 ± 3.28 years. At the mean follow-up of 3.64 ± 1.97 years (range, 2-8.8 years), outcome was fair to good in 8 (72.7%) and poor in 3 (27.3%) cases. Average union time was 13.5 ± 1.77 weeks. Complication rate was 72.7%. Avascular necrosis occurred in three cases (27.3%). Six patients (54.5%) developed coxa vara, with a mean neck-shaft angle of 102.16° ±12.07° (range, 90°-118°). Five patients (45.5%) had leg length discrepancy with a mean 18 mm (range, 7-35 mm). DISCUSSION local conditions negatively influenced the management of femoral neck fractures. Conservative treatment led to many complications which increase the cost of management.
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Affiliation(s)
- Jean Baptiste Yaokreh
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Thierry-Herve Odehouri-Koudou
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Gaudens Atafy Dieth
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Samba Tembely
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Yapo Guy-Serge Kouame
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Bertin Dibi Kouame
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Ossenou Ouattara
- Department of Mother and Children, University of Félix Houphouet Boigny Pediatric Surgery Unit, CHU Yopougon, Côte d'Ivoire, Abidjan, Côte d'Ivoire
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Abstract
Bilateral femoral neck fractures are rare in the pediatric age
group, and only a few cases have been reported following
major trauma in children. A 9-year old girl presented with
bilateral femoral neck fractures following a motor vehicle
accident. The patient was managed with early operative
fixation of the fractures with a successful outcome. This case
highlights the importance of awareness of the occurrence of
bilateral femoral neck fractures in the polytrauma patients.
This case is presented due to its rarity.
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Affiliation(s)
- D Dhar
- Department of Orthopaedics, Regional Referral Hospital, Nizwa, Oman
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