Complications associated with fracture of the neck of the femur in children

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.

Long-term results of valgus intertrochanteric osteotomy for partial avascular necrosis of the femoral head after femoral neck fracture in adolescents

PURPOSE

The study evaluates long-term results in patients treated by valgus intertrochanteric osteotomy (VITO) for partial avascular necrosis of the femoral head (ANFH) after fracture of the femoral neck in adolescent age. Although this method is mentioned in literature frequently, there are only few studies in the literature dealing with it in detail.

METHODS

Authors evaluated five patients at the interval of 15 to 20 years following VITO. The mean age of the patients at the time of injury was 13.6 years and at the time of VITO 16.7 years. The studied parameters included resorption of necrotic segment of femoral head, development of posttraumatic osteoarthritis and leg shortening.

RESULTS

Comparison of radiographs and MRI scans before and after VITO showed resorption of the necrotic segment of the femoral head and its remodeling in all five patients. However, two patients gradually developed slight osteoarthritic changes. In one patient, remodeling of the femoral head occurred during the first 6 years postoperatively. Subsequently, the patient developed severe osteoarthritis with marked clinical symptoms.

CONCLUSION

VITO can improve the long-term function of the hip joint in adolescents with ANFH after a femoral neck fracture, but cannot restore completely the original shape and structure of the femoral head.

High-Degree Valgus Osteotomy for Severe Femoral Head Osteonecrosis After Femoral Neck Fracture with Nonunion: A Case Report

CASE

A 15-year-old adolescent boy had severe groin pain because of extensive osteonecrosis of the femoral head with collapse, joint space narrowing, and nonunion after a failed internal fixation for femoral neck fracture. We performed a 60° valgus osteotomy that moved the posteromedial small viable portion of the femoral head to the weight-bearing acetabular area. The femoral neck nonunion and the necrosis healed completely, and the spherical contour of the femoral head was regained after postoperative hip joint remodeling.

CONCLUSIONS

Good remodeling and congruency were achieved by performing high-degree valgus osteotomy to obtain sufficient viable area below the acetabular roof.

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.

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.

Traumatic Hip Dislocation Associated with Proximal Femoral Physeal Fractures in Children: A Systematic Review

Traumatic hip dislocation might lead to serious complications and a poor outcome. Fortunately, it is a rare condition in pediatric patients. The purpose of this study is to establish and describe the complications caused by hip dislocations associated with transphyseal femoral neck fractures. Therefore, we conducted a literature review that resulted in 11 articles, including 32 patients, older than 10 years of age, suffering from traumatic hip dislocation associated with a transphyseal femoral neck fracture. We presented a case series of three patients with hip fracture-dislocation treated in our clinic that were also evaluated and included in the study. For the 35 patients included in the study group, the percentage of avascular osteonecrosis after hip fracture-dislocation was 88.57%. Traumatic hip dislocation associated with transphyseal femoral neck fracture is a rare condition and has a poor prognosis because of the high incidence of femoral head avascular necrosis (AVN). Reduction should be attempted within six hours the from injury, but this may not minimize the risk of AVN if transphyseal separation occurs. The approach may influence the development of AVN; lateral approach of the hip with great trochanter osteotomy seems to have the lowest number of cases of AVN.

Pathological progress of traumatic femur head necrosis after femoral neck fracture in children and adolescents: a case series study

The pathological progression and prognosis of traumatic femur head necrosis (TFHN) after femoral neck fracture (FNF) in children and adolescent is relatively unknown and has never been specifically characterized. As we speculated, the prognosis in such population would be poor and characterized as the high risk of femoral head collapse, hip deformity and degeneration in a short term. This retrospective case series enrolled 64 children and adolescent with TFHN who treated with observational treatment from 2000.1 to 2018.1. The primary outcomes, the progression of femoral head collapse, hip deformity (Stulberg classification) and hip degeneration (Tönnis grade), and their prognostic factors were analysed. Sixty-four patients with a mean age of 13 years (6-16 years) were included. A total of 28 hips (44%) showed unsatisfactory outcome and 25 (39%) hips collapsed progressively during a mean follow-up of 48 months (24-203 months). Finally, 38 hips (59%) experienced hip deformity, 20 of them were Class IV/V. Thirty-four hips (53%) generally progressed to osteoarthritis, 14 of them were classified as Grades II/III. The location of the lesion and the presence of subluxation were found to be related to progression of collapse; however, the presence of subluxation was the only independent risk factor of severe hip deformity and degeneration. TFHN in children and adolescent is a rapidly progressing disease with a poor prognosis characterized by a high risk of femoral head collapse progression. If the subluxation emerged, collapsed cases showed increasingly tendency towards hip deformity and degeneration.

Bilateral Fracture Neck Femur in Child with Bilateral Delayed Union and Bilateral AVN: A Rare Occurrence and Literature Review

A bilateral neck of femur fracture in children is a rare occurrence with only twelve cases reported till the date. We report a case of a 3-year-old schoolgirl with bilateral Delbet type 2 fracture neck femur after a fall from height. She was managed elsewhere by bilateral closed reduction and screw fixation within 24 h. She presented to us three months after surgery with painful hip movements and inability to walk. Her X-ray showed bilateral Ratliff type three avascular necrosis and bilateral delayed union with visible fracture lines. We placed her in double hip spica for three months. Fortunately, on both sides fractures united well with complete resolution of avascular changes. At one year follow-up, she had no functional limitation, no limb length discrepancy, and an x-ray showed mild coxa vara on left. Bilateral delayed union and avascular necrosis of fracture neck femur has not been reported till date.

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.

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.

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.

Analysis of risk factors for complications after femoral neck fracture in pediatric patients

BACKGROUND

Pediatric femoral neck fracture is a rare injury but yields frequent complications. However, there is a paucity of data regarding the risk factors for these complications.

PURPOSE

The present article reports the rate of complications after femoral neck fracture in pediatric patients and investigates the possible risk factors.

METHODS

We retrospectively reviewed 44 children (mean age of 9.0 years, range from 2 to 14 years) who were surgically treated for femoral neck fracture in a single trauma center with a mean follow-up of 57.75 months (range from 11 to 224 months). Related clinical factors were recorded and analyzed by multivariable logistic regression.

RESULTS

Fracture displacement or Delbet-type fracture had no relation to the injury mechanism. However, younger children experienced severe trauma, combined injury, and low fracture location more than older individuals did. Children with combined injuries were more likely to have a longer waiting time for surgical reduction. Common complications included avascular necrosis (AVN) in 14 cases, nonunion of fracture in 2 cases, coxa vara in 4 cases, and premature physeal closure (PPC) in 7 cases. Only the Delbet type was an independent predictor of AVN (OR = 0.14, p = 0.030). Inadequate reduction was associated with higher rates of coxa vara (OR = 33.19, p = 0.032). Epiphysis penetration in children younger than 10 years old increased the rate of PPC (p = 0.032). No significant risk factor was found for fracture nonunion.

CONCLUSION

For femoral neck fracture in pediatric patients, both the injury mechanism and fracture characteristics have age-related distributions. Early reduction should be carried out as early as possible based on the safe condition of the child, but for younger children, transepiphyseal fixation should be avoided. AVN may be intrinsic to injury characteristics rather than resulting from the choice of treatment mode.

Femoral Neck Fractures in Children: Issues, Challenges, and Solutions

Femoral neck fractures in children are rare injuries resulting from high-energy trauma. Different methods of treatment, lack of standard management protocols, and the high risk of complications make this injury one of the biggest challenges that an orthopaedic surgeon can face. This review focuses on the general aspects of the pediatric femoral neck fracture management as well as its complications and possible solutions.

Surgical treatment with cannulated screws for pediatric femoral neck fractures: A case series

INTRODUCTION

Femoral neck fractures are uncommon injuries in children, but the high incidence of long-term complications makes it important clinical entity. Early surgical treatment to achieve optimal results and to avoid a high rate of complications is widely advised. The purpose of this study was to retrospectively analyze the outcome of 8 children who sustained a femoral neck fracture.

PATIENTS AND METHODS

The patients (6 boys and 2 girls with an average age of 9.2 years) were treated within 24 h following admission to hospital by closed reduction and internal fixation. The type of fracture was distinguished according to Delbet's classification system. The outcome was analyzed using Ratliff's criteria, and a detailed record of complications was maintained.

RESULTS

According Delbet's classification system, there were 3 type I, 2 type II, 2 type III, and 1 type IV fractures. The average follow-up was 39.2 months (range 8-95). A satisfactory outcome was obtained in 6 (75%) children. Avascular necrosis was the most notable complication, which was reported in the 2 fair outcomes (25%).

CONCLUSIONS

Early and aggressive surgical treatment aimed at anatomical reduction result in a satisfactory outcome in pediatric femur neck fractures. Development of avascular necrosis is the main complication.

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.

Surgical treatment of neglected hip fracture in children with cerebral palsy: case report and review of the literature

CASE

A clinical case of a 15-year-old cerebral palsy child with a Sandhu type 2 neglected femoral neck fracture is presented. The patient was treated using cannulated screws and cancellous bone graft augmented with mesenchymal stem cells. At 6 months after the surgery complete fracture healing was observed.

CONCLUSION

To early diagnose this fractures, it is mandatory to perform a comprehensive clinical and radiological evaluation including also a second level imaging. The use of cannulated screws with cancellous bone graft and MSCs is a viable treatment option in these patients.

Bilateral femoral neck fractures associated with complex pelvic ring injuries in a pediatric patient: a case report

Femoral neck and pelvic fractures are rarely encountered in the pediatric population secondary to the resilient nature of the immature skeleton. Both fracture types usually result from high-energy blunt trauma including motor vehicle collisions, motor vehicle-pedestrian accidents, and falls from height. Considerable studies have been published on the natural history, management, and complications of pediatric pelvis and femoral neck fractures. However, few case reports have documented both fracture types in the same patient. Management of concomitant injuries presents unique challenges both for operative stabilization and for clinical postoperative care. After appropriate consent was obtained, a thorough review was performed of the patient's hospital records and imaging history. The senior author of the report also provided insight into the management of the patient's initial injuries and subsequent complications. Our case involves a 4-year-old female who was overrun by an all-terrain vehicle. Her orthopedic injuries included a nondisplaced Delbet type 3 fracture of the right femoral neck, a completely displaced Delbet type 3 fracture of the left femoral neck, bilateral sacroiliac fracture-dislocations, severe comminution of her left pubic rami, and a free-floating right pubic rami segment spanning from the triradiate cartilage to the pubic symphysis with severe rotational deformity. Her postoperative recovery was complicated by refracture of her left femoral neck (Delbet type 1), left hip osteomyelitis, and left femoral head avascular necrosis. The salient features of her operative management, subsequent complications, and functional recovery are described in this report. Cases of bilateral femoral neck fractures and multiple pelvic fractures in pediatric patients are sparsely documented in the literature because of their infrequent occurrence. Pediatric pelvic fractures typically do well with conservative treatment secondary to the incredible remodeling ability of the immature pelvis. Femoral neck fractures, in contrast, are highly associated with complications including coxa vara, nonunion, infection, physeal closure, and avascular necrosis. This case report documents two rare fracture types in the same patient and describes the challenges encountered throughout the duration of her recovery.

LEVEL OF EVIDENCE

Level V, Case report.

Fibular strut graft for nonunited femoral neck fractures in children

PURPOSE

To evaluate the clinical and radiological outcomes of using fibular strut grafts as a fixation device for non-united femoral neck fractures in children with or without subtrochanteric valgus osteotomy.

METHODS

A total of 12 children with non-united femoral neck fractures (nine males and three females) with an average age of 8.2 years (5 to 12) were managed, and functional results evaluated, between July 2013 and July 2015. The mechanisms of injury were fall from a height in ten patients and road traffic accident in two cases. Nine cases of femoral neck nonunion followed failed internal fixation and three cases were neglected fractures. Six cases were treated by fibular strut graft and subtrochanteric valgus osteotomy with contoured plate and six cases were treated by fibular strut graft and hip spica.

RESULTS

The mean follow-up period was 20.4 months (12 to 36). Union was achieved in all 12 cases by a mean of 3.5 months (2.5 to 6). All patients were satisfied at five months. For final analysis of clinical and radiographic results, the Ratliff's classification was used. We classed 11 cases as good results and one case as fair.

CONCLUSIONS

Fibular strut grafts are a reliable option for treatment of pseudo-arthrosis in femoral neck fracture nonunion in children. It is successful in restoration of femoral neck length in children with non-united femoral neck fractures.

Transphyseal Femoral Neck Fracture in a Twenty-Month Old Male Child

Transphyseal femoral neck fractures are an extremely rare event, mainly occurring in children subjected to an significant traumatic force. The diagnosis is usually suggested by clinical examination with radiographic confirmation. Management varies; however, no consensus exists as to proper treatment. Intervention is primarily focused on the prevention of avascular necrosis (AVN) of the femoral epiphysis.

We present the case of a 20-month-old male with a delayed diagnosis of transphyseal femoral neck fracture. X-ray (XR) and computed tomography (CT) scan images were used for diagnosis, to track healing, and monitor the possible emergence of avascular necrosis. Final imaging demonstrated full healing without AVN at two years.

This study demonstrates the successful treatment of a rare pediatric fracture type with possible life-changing complications. Reduction, surgical fixation with K-wires, and spica casting are demonstrated as being acceptable treatment in the very young transphyseal fracture patient.

Osteonecrosis After Femoral Neck Fractures in Children and Adolescents: Analysis of Risk Factors

BACKGROUND

The most serious complication of femoral neck fractures in children and adolescents is osteonecrosis. Although a number of factors have been implicated in the development of osteonecrosis, no specific cause-and-effect relationship has been determined. The primary purpose of this study was to determine the prevalence of osteonecrosis in children and adolescents after femoral neck fractures and to identify risk factors for its development.

METHODS

This retrospective review identified 70 patients between the ages of 1.3 and 18.1 years who were treated for a femoral neck fracture between 2000 and 2011 at a single level I pediatric trauma center and followed until clinical and radiographic union. Demographic information, injury event details, type of surgical treatment, associated injuries, time from injury to treatment, and postoperative alignment were recorded from chart and radiographic review. The primary outcome was the presence of osteonecrosis, which was determined by review of available imaging. Multivariable logistic regression analysis tested age, time to treatment, type of fixation, mechanism of injury, postoperative alignment, and capsular decompression as possible risk factors for the development of osteonecrosis.

RESULTS

Osteonecrosis occurred in 20 (29%) of the 70 patients. The median time to diagnosis of osteonecrosis was 7.8 months. Multivariable predictors of osteonecrosis included fracture displacement (P=0.01) and fracture location (P=0.02). Patient age, type of fixation, mechanism of injury, capsular decompression, postoperative alignment, and performance of reduction were not predictive of osteonecrosis after femoral neck fracture. Finally, time to treatment also was found to be a positive predictor of osteonecrosis (P=0.004), with osteonecrosis more likely in patients treated in less than 24 hours, but this finding is likely due to confounding because injury severity was closely linked to time to treatment.

CONCLUSIONS

Regardless of the treatment, the prevalence of osteonecrosis after femoral neck fractures remains high. Recognizing factors that are predictive of the development of osteonecrosis can help surgeons counsel patients and families appropriately about the risk of this complication.

Vascular evaluation after cervical hip fractures in children: a case series of eight children examined by scintigraphy after surgery for cervical hip fracture and evaluated for development of secondary radiological changes

Femoral neck fractures in children and young adults are rare, but have a high risk of avascular necrosis (AVN) and subsequent gradual collapse of the femoral head. In 2006, we initiated the use of scintigraphy for the diagnosis of vascular impairment after a cervical fracture in children. In the present retrospective case study, we evaluated the effect of the remaining postoperative circulation in the femoral head after fracture in terms of the development of AVN and secondary degenerative changes of the hip joint. Eight children, four girls and four boys [mean age 11.5 years (7-16)], had been operated for a cervical or a basocervical hip fracture between 2006 and 2012. The femoral head circulation was evaluated postoperatively with scintigraphy and all children had been followed radiographically for a minimum of 1 year. The Ficat classification was used to stage the AVN and the Stulberg classification was used to stage the sphericity of the femoral head at follow-up. In two patients, the femoral head had normal circulation postoperatively and they also had normal radiographs at follow-up. In two patients, the entire femoral head was avascular postoperatively and at follow-up, one patient had normal radiographs and one had both subchondral sclerosis and flattening. These two patients had been treated with bisphosphonates and prolonged non-weight-bearing. Four patients had postoperatively retained circulation in parts of the femoral head. Three of these four patients had normal radiographs at follow-up. Evaluation of the remaining circulation after surgery may help to predict the outcome and guide the postoperative regime in children with a femoral neck fracture.

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.

Delayed Slipped Capital Femoral Epiphysis After Treatment of Femoral Neck Fracture in Children

BACKGROUND

Slipped capital femoral epiphysis (SCFE) after the treatment of femoral neck fracture is a rare entity in children that poses important treatment challenges.

CASE DESCRIPTION

We describe the presentation and management of two patients, a 12-year-old girl and a 6-year-old girl, each of whom developed SCFE at 5 months and 9 months, respectively, after operative treatment of femoral neck fracture.

LITERATURE REVIEW

Five similar cases have been reported in the literature. Along with our two case studies, the average age of all seven patients was 8.9 years (range, 3.6-12 years; boys, 8.9 years; girls, 9 years). None of the children was in a high weight percentile or had any known endocrinologic disorder. Two had asymptomatic mild SCFE, whereas the others felt unexplained pain with ambulation when the slippage was brought to their attention. Although it is not possible to prove a causal relationship between the initial fracture and the subsequent SCFE, clinical factors such as implant irritation, early return to weightbearing, delayed union or nonunion, coxa vara, and avascular necrosis warrant consideration as potentially related to the subsequent slip.

CLINICAL RELEVANCE

The onset of SCFE after surgical treatment of a femoral neck fracture may reflect inadequate treatment of the fracture. For best practice, we should perform a gentle anatomic reduction, appropriate internal fixation for femoral neck fracture in skeletally immature patients. Postoperative cast immobilization and delayed weightbearing are also important to avoid complication. It is essential for pediatric orthopaedic surgeons to be aware of this clinical scenario to allow prompt recognition and patient treatment.

Earlier time to reduction did not reduce rates of femoral head osteonecrosis in pediatric hip fractures

OBJECTIVES

Hip fractures account for less than 1% of all pediatric fractures; however, femoral head osteonecrosis (ON) after this injury ranges from 0% to 92%. The aim of this investigation was to add our experience to the literature and identify factors that may increase or decrease the risk of ON in pediatric patients with hip fractures.

DESIGN

Institutional review board-approved retrospective review.

SETTING

Pediatric level II trauma center.

PATIENTS/PARTICIPANTS

Two hundred fifty-five pediatric hip fracture cases were reviewed from 1983 to 2009. Children were excluded if they had metabolic bone disease, subtrochanteric or pathologic fractures, slipped capital femoral epiphysis, or less than 1 year follow-up. This left 43 patients with 44 fractures in the study.

INTERVENTION

Standard fixation procedures.

MAIN OUTCOME MEASUREMENTS

Factors that could influence ON were analyzed and included age, Delbet classification, displacement, time to reduction, reduction quality and type, and whether a decompression was performed. Fisher exact tests were used with P <0.05 considered statistically significant.

RESULTS

Of the 44 cases included in the study, 9 (20%) developed ON. Age ≥11 years was the only statistically significant independent predictor of ON (P = 0.04). The details of 3 unique cases are also presented.

CONCLUSIONS

The rate of ON in this case series was 20%. No ON occurred in any child <11 years old. We were unable to demonstrate that earlier time to reduction reduced the incidence of ON.

LEVEL OF EVIDENCE

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

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.

Case report: Bilateral femoral neck fractures in a child and a rare complication of slipped capital epiphysis after internal fixation

BACKGROUND

Bilateral traumatic femoral neck fractures are uncommon in children. The most commonly reported complications are nonunion, avascular necrosis of the femoral head, and chondrolysis. Slipped capital femoral epiphysis (SCFE) associated with nonunion after percutaneous partially threaded cancellous screw (PTCS) fixation of the fracture is an unreported complication.

CASE DESCRIPTION

We describe a 10-year-old boy who had bilateral femoral neck fractures secondary to a fall from a height. The patient was treated with percutaneous PTCS fixation on both sides and achieved union on the right side in 3 months, however, a nonunion and SCFE developed on the left side 5 months after the initial surgery. Management of the nonunion and SCFE with PTCS and nonvascularized fibula graft led to union. Eighteen months after the initial injury, the patient achieved a pain and limp-free gait.

LITERATURE REVIEW

A literature review shows avascular necrosis, posttraumatic coxa vara, premature physeal closure, nonunion, chondrolysis, infection, and implant failure as complications of operative management of femoral neck fractures. SCFE has not been previously reported.

PURPOSES AND CLINICAL RELEVANCE

This case highlights the need for close followup of adolescent patients with PTCS fixation for femoral neck fractures.

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

Concomitant ipsilateral fractures of the neck and shaft of the femur in children are rare. The most recent report in this context found a total of only nine reported cases (<12 years of age) following a search of the indexed English literature. These injuries occur in children due to high-velocity trauma, and there is no generally accepted method of treatment. We report three additional cases from the literature and two cases of our own. In our cases, one had a residual 10° varus deformity at the subtrochanteric level in the femur, but this did not affect hip function. Another patient exhibited a limp at final follow-up due to leg length discrepancy, and peroneal nerve palsy at the time of injury. We advocate operative stabilization of the femoral shaft fracture first to reduce the risk of further displacement and simplify the subsequent reduction of the femoral neck. The series shows that these rare injuries have a poor prognosis, with high rates of incidence of avascular necrosis, coxa vara, and leg length discrepancy.

Joint chondrolysis

Although the disease was first described in the hip, reports of chondrolysis in nearly all diarthrodial joints have since emerged with considerable variations in the literature.Despite speculation among clinicians and researchers about the implicit causal pathways and etiologic contributors associated with chondrolysis, definitive answers remain elusive.The term chondrolysis has been applied to varied levels of joint cartilage destruction from focal chondral defects to diffuse cartilage loss, revealing a lack of consistency in the application of diagnostic criteria to guide differential disease classification.Differentiating between the various potential etiologies associated with chondrolysis provides opportunities for the prevention of the disease.

Operative treatment of avascular necrosis of the femoral head after proximal femur fractures in adolescents

PURPOSE

Our aim was to assess operative treatment for post-traumatic avascular necrosis of the femoral head (ANFH) in adolescents.

METHODS

Eleven patients with an average age of 17 (range 14-26) years were operated up on for ANFH after proximal femoral fractures. The average interval between injury and reconstructive surgery was four (range two to eight) years. The average follow-up of the entire cohort was 89 (range 48-132) months. Five patients with total ANFH were treated by total hip replacement (THR). Six patients with partial ANFH were treated with valgus intertrochanteric osteotomy (VITO).

RESULTS

In all patients, operation improved hip function. The average preoperative Harris Hip Score (HHS) was 70 points and average postoperative HHS was 97 points. Comparison of magnetic resonance imaging (MRI) scans before and after VITO demonstrated resorption of the necrotic segment of the femoral head and its remodelling in all six patients with partial ANFH. A complication was encountered in one patient.

CONCLUSION

Patients treated for ANFH had good medium-term outcomes after THR for total necrosis and also after VITO for partial necrosis.

Operative treatment of avascular necrosis of the femoral head after slipped capital femoral epiphysis

PURPOSE

The aim of the study was assessment of the medium-term outcome of operative treatment of avascular necrosis of the femoral head (ANFH) after slipped capital femoral epiphysis (SCFE).

MATERIALS AND METHODS

Five patients were treated with valgus-flexion intertrochanteric osteotomy (VFITO) for partial ANFH that developed after operative treatment. Their average age at the time of slip was 12.5 years (range, 10-14); at the time of the reconstructive operation 14 years (range, 12-16), the average interval between slip and the reconstructive operation was 14 months (range, 9-18). Partial ANFH was diagnosed between 6 and 8 months after the slip on the basis of radiographic examination. In all the patients, the anterolateral third up to half of the femoral head was always affected. The average follow-up period was 73 months (range, 60-84).

RESULTS

Comparison of MRI scans before and after VFITO proved resorption of the necrotic segment of the femoral head and its remodeling in all the five patients. The average preoperative Harris hip score (HHS) was 86 points, the average postoperative HHS was 94 points.

CONCLUSION

VFITO provides a good outcome at medium-term follow-up in adolescent patients with partial ANFH after SCFE.

Displaced fracture of the femoral neck in children: open versus closed reduction

We have investigated whether early anatomical open reduction and internal fixation (ORIF) reduces the incidence of complications of fracture of the femoral neck in children, including avascular necrosis, compared with closed reduction and internal fixation (CRIF). We retrospectively reviewed 27 such fractures (15 type-II and 12 type-III displaced fractures) in children younger than 16 years of age seen in our hospital between February 1989 and March 2007. We divided the patients into three groups according to the quality of the reduction (anatomical, acceptable, and unacceptable) and the clinical results into two groups (satisfactory and unsatisfactory). Of the 15 fractures treated by ORIF, 14 (93.3%) had anatomical reduction and reduction was acceptable in one. Of the 12 treated by CRIF, three (25.0%) had anatomical reduction, eight had acceptable reduction (66.7%), and one (8.3%) unacceptable reduction. Of the 15 fractures treated by ORIF, 14 (93.3%) had a good result and one a fair result. Of the 12 treated by CRIF, seven (58.3%) had a good result, two (16.7%) a fair result and three (25.0%) a poor result. There were seven complications in five patients. ORIF gives better reduction with fewer complications, including avascular necrosis, than does CRIF in fractures of the femoral neck in children.

Nonunion of capital femoral physeal fracture with a large metaphyseal fragment

This report presents a case demonstrating the nonunion of a capital femoral physeal fracture with a large metaphyseal fragment in a 10-year-old boy. To our knowledge, there is no previously reported case of this type of nonunion. The treatment of this nonunion presented a potential risk of premature physeal closure and avascular necrosis of the femoral head, so internal fixation using cannulated screws and percutaneously drilling with a Kirschner wire to the metaphyseal fragment was used and was effective in bone union without these complications.

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.

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.

Delayed fixation of the transcervical fracture of the neck of the femur in the pediatric population: results and complications

PURPOSE

To determine the impact of a substantial delay in providing surgical treatment on the final outcome in transcervical femoral neck fractures in children.

METHODS

Data on all pediatric patients with transcervical fractures of the femoral neck that were fixed by reduction and internal fixation after a delay of ≥7 days in our department between 2000 and 2008 were collected both retrospectively and prospectively.

RESULTS

The medical records of 14 patients (15 fractures) were analyzed. The results after an average of 43 months of follow-up showed that the complication and avascular necrosis rates were higher in cases in which treatment had been delayed compared to those in comparable fractures that had been treated promptly after the event in other series. Nine of the 15 fractures had developed avascular necrosis at final follow-up. Overall, there were four excellent, three good, and eight poor results (based on the Ratliff criteria).

CONCLUSIONS

Children whose transcervical fractures of the femoral neck were surgically treated after a delay of 1 week or longer had a high avascular necrosis rate and a relatively poor outcome. Reduction and internal fixation as the initial treatment should be implemented shortly after injury in order to enhance treatment outcome.

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.

Traumatic transepiphyseal separation of the upper femoral epiphysis following seizures in two children with cerebral palsy

Transepiphyseal separation of the neck of the femur following grand mal seizures is described in two children with cerebral palsy. Closed reduction and percutaneous fixation was followed by a period in a hip spica. Although the incidence of avascular necrosis of the femoral head is high following such injury, this has not occurred in these patients at a follow-up of 18 months.

Nonunion of fractures of the femoral neck in children

The authors present the prospective clinical outcome of nine pseudoarthroses resulting from surgical treatment carried out in nine children, whose ages varied from 6 years and 2 months to 14 years and 2 months (mean 10 years and 2 months), who had fractures of the femoral neck. Five were classified as type II, according to the Delbet classification modified by Colonna, and four were type III. The initial fractures were caused by high-energy traumas, such as trampling, bicycle falls, and car accidents. Treatment of choice was valgus osteotomy of the femoral neck associated or not with insertion of bony graft. The mean time of follow-up was 38 months, ranging from 23 to 71 months, and the mean time of pseudoarthrosis consolidation after osteotomy was 76.6 days, varying from 45 to 240 days. In this study, all the pseudoarthroses consolidated. For final analysis of clinical and radiographic results, the Ratliff's classification was used. We obtained three cases as good results, five as fair and one as poor. The authors concluded that valgus osteotomy is a good option for treatment of pseudoarthrosis in the femoral neck fractures in children.

Modified Pauwels' intertrochanteric osteotomy in neglected femoral neck fractures in children: a report of 10 cases followed for a minimum of 5 years

OBJECTIVES

To evaluate the role of a modified Pauwels' intertrochanteric osteotomy (MPIO) in neglected femoral neck fractures in children.

DESIGN

Prospective study with retrospective analysis.

SETTING

Tertiary care Postgraduate Institute of Medical Sciences.

PATIENTS

Ten children (8 males, 2 females) with an average age of 10.2 years with neglected femoral neck fractures were seen from 1990 to 1998. A femoral neck fracture was considered neglected when no proper medical treatment was instituted for at least 1 month following the fracture. Nonunion was accompanied by coxa vara and resorption of the femoral neck in 9 patients; a 10th patient had a neglected femoral neck fracture for 1 month without coxa vara. Three patients at time of presentation with Delbet Type II displaced fractures with associated nonunion and coxa vara (2 with Ratliff Type III and 1 with Type I) also had avascular necrosis using plain radiographic criteria of increased density.

INTERVENTION

Modified Pauwels' intertrochanteric osteotomy. The children were immobilized in a hip spica for 6-10 weeks postoperatively and weightbearing was started after hip spica removal.

MAIN OUTCOME MEASUREMENTS

Fracture healing, neck-shaft angle, avascular necrosis, and functional outcome.

RESULTS

Patients were followed for an average of 8.2 years (range 5-12 years). All patients had union of their fracture within an average of 16.6 weeks (12-20 weeks) and of the osteotomy site within 8.2 weeks (7-9 weeks). Radiologic signs of avascular necrosis disappeared completely in the 3 patients who presented with avascular necrosis. In 1 patient with a preoperatively viable femoral head, radiologic signs of Ratliff Type I avascular necrosis appeared between 60 and 98 weeks. This radiologic finding became normal again, indicating viability of the femoral head somewhere between 98 to 205 weeks of follow-up. Postoperatively, an average of 135-degree neck-shaft angle was achieved (range 125-160 degrees). The average preoperative neck-shaft angle was 104.4 degrees (range 92-120 degrees) and on the normal hip side it was 127.7 degrees (range 124-132 degrees). Significant improvement in the neck-shaft angle was seen compared with the preoperative angle (P < 0.001) and normal hip angle (P < 0.05). Coxa vara and signs of chondrolysis were not observed in any of the patients. Premature proximal femoral epiphyseal closure resulting in a 1-cm and a 1.5-cm leg-length discrepancy was seen in 2 patients as compared with their normal side. A mild Trendelenburg gait was observed in 1 patient (10%). Using Ratliff's criteria, 9 patients (90%) were graded as a good result and 1 patient (10%) was graded as a fair result. The osteotomy plate was removed in 1 patient (10%).

CONCLUSION

An MPIO creates a biomechanical environment conducive to healing of a neglected femoral neck nonunion in a child while simultaneously correcting an associated coxa vara. The procedure also seems to have a biological role in helping restore viability to a noncollapsed femoral head with avascular necrosis.

A transepiphyseal fracture of the proximal femur combined with a fracture of the mid-shaft of ipsilateral femur in a child: a case report and literature review

The paper describes a rare fracture of proximal femur, classified by Delbet (Am J Surg 6:793-797, 1929) as type I (transepiphyseal type) combined with a fracture of the midshaft of ipsilateral femur in a 2-year-old child. Immediate operation with open reduction and internal fixation was successful. During the postoperative course, avascular necrosis (AVN) of capital femoral epiphysis was seen by bone scan. Applying an abduction orthosis used for the treatment of Legg-Calvè-Perthes disease, collapse of capital epiphysis was prevented. Although, a minimal area of AVN and coxa vara remained, no clinical complaints were recorded at the midterm follow-up. While reviewing the relevant literature, the type-I fractures need to be subclassified into two types for appropriate treatment and/or prediction of outcomes based on their anatomic location of the separated femoral capital epiphysis. In type Ia, femoral capital epiphysis is minimally displaced and within the acetabulum and in type Ib it is widely displaced and lying outside the capsule. Our case is a first case of a type Ib fracture of the proximal femur combined with a fracture of the midshaft of ipsilateral femur. Since the complication rate and the prognosis differed between two subclasses, type-Ib fractures need immediate surgical intervention, our case was prevented from massive AVN. And to prevent the collapse of femoral head following AVN, a major complication of the fracture of proximal femur in child, abduction orthosis is recommended as a choice of treatment.

Risk factors for avascular necrosis after femoral neck fractures in children: 25 Cincinnati cases and meta-analysis of 360 cases

PURPOSE

Avascular necrosis (AVN) is one of the most serious complications of femoral neck fractures in children. Variability in the reported rates of AVN and lack of statistical evidence has minimized the prognostic power of individual studies. The purpose of our study was to review our own cases as well as those from the literature in an effort to identify the risk factors for AVN.

METHODS

We conducted a computerized search of medical records to identify all children with femoral neck fractures treated at our institution from 1980 to 2003. Records were reviewed to determine fracture type (Delbet type I to IV), displacement, age, treatment, and incidence of AVN. A structured search of PubMed was also performed to identify all reports published in English, on femoral neck fractures in children, from 1965 to 2003. Hand searches of major orthopedic journals and reference lists of publications identified additional cases. Of the 275 citations initially identified through our computerized search, 47 met the criteria for further evaluation. These citations were reviewed by 2 investigators, and data was abstracted from 20 reports that provided patient-level data and met our criteria for inclusion.

RESULTS

Twenty-four patients with 25 femoral neck fractures from our institution were identified including 12 boys and 12 girls with an average age of 8 years (range 1.5 to 16). Over 300 patients who met our study criteria were also identified from the literature, and a total of 360 patients were included in the analysis. Fracture type, displacement, age, and treatment were all statistically significant independent predictors of AVN with P values <or=0.05. With logistic regression analysis, however, fracture type and age were identified as the only significant predictors of AVN. Older children were 1.14 times more likely to develop AVN for each year of increasing age. Type I to III fractures were 15, 6, and 4 times, respectively, more likely to develop AVN than type IV fractures. AVN rate by Delbet class was I=38%, II=28%, III=18%, and IV=5%.

CONCLUSION AND SIGNIFICANCE

Although several factors may contribute to the development of AVN, our meta-analysis provides statistical evidence that fracture type and age are the most significant predictors.

Fractures of the hip in children

Fractures of the hip are uncommon in children, and their importance is related not to the frequency of the injury but to the frequency of complications. Many of these complications can be minimized or avoided by anatomic reduction and internal fixation. Open reduction frequently is necessary to obtain a stable, anatomic reduction. Regardless of the age of the child, stable fixation of the fracture must be given priority over preservation of the proximal femoral physis. The development of osteonecrosis, however, is most likely related to the severity of the initial injury and is largely unaffected by treatment of the fracture.

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

Twenty-six children and adolescents with displaced femoral neck fractures who were treated surgically from 1992 to 2002 were included in this study. Among them, 14 were male and 12 were female. Altogether, 10 of them had a transcervical type of fracture, and the other 16 had a cervicotrochanteric type of fracture. The average age of the patients was 10.8 years (3-17 years). Seventeen were treated by closed reduction and internal fixation (group A), and nine required open reduction and internal fixation (group B). In group A, there were good results in 11 cases (65%), a fair result in one case (6%), and poor results in 5 cases (29%). In group B, there were good results in seven cases (78%) and fair results in the other two cases (22%). The average fracture union times in groups A and B were 12.6 and 10.2 weeks, respectively. Thus, there was a favorable outcome in group B. However, statistical analysis of data in this preliminary study did not reveal any significant difference in the surgical outcome between the two groups.

Pathologic fractures in children

Fractures through bone tumors are often difficult to treat. We reviewed our combined experience with this problem in children, as well as the existing literature, to formulate management guidelines. For this study, prospective databases (1987 to 2002) from three referral centers were screened for pathologic fractures occurring under the age of 14 years. One hundred five patients presented with fracture through unicameral bone cyst, nonossifying fibroma, fibrous dysplasia, aneurysmal bone cyst and osteosarcoma. Seventeen patients were excluded. The most common primary locations were the proximal humerus and proximal femur. Pathologic fracture through nonossifying fibroma had the best outcome; union occurred with nonsurgical treatment in all cases. Unicameral bone cyst required surgical treatment to avoid persistence of the cyst and refracture. However fracture healing was predictable without surgical treatment. Proximal femoral lesions tended to heal in malunion if not fixed surgically. Aneurysmal bone cyst required surgical treatment for the lesion to heal and to allow the fracture to heal as well. Percutaneous sclerotherapy may be the treatment of choice for many of these lesions. Fibrous dysplasia allows fracture healing with nonoperative therapy. Progressive deformity requires followup and surgical correction. Malignant lesions presenting a pathologic fracture are best managed by initial nonoperative therapy during investigation and neoadjuvant therapy when possible, followed by definitive treatment.