Pediatric fracture neck of femur

Sandeep K Yadav; Alok C Agrawal; Bikram Keshri Kar; Harshal S Sakale; Bikas Sahoo; Rahul K Chandan

doi:10.4103/jodp.JODP_7_18

SYMPOSIUM: FRACTURE NECK OF FEMUR

Year : 2018 | Volume : 1 | Issue : 1 | Page : 11-14

Pediatric fracture neck of femur

Sandeep K Yadav, Alok C Agrawal, Bikram Keshri Kar, Harshal S Sakale, Bikas Sahoo, Rahul K Chandan
Department of Orthopaedics, All India Institutes of Medical Sciences (AIIMS), Raipur, Chhattisgarh, India

Date of Web Publication

28-Dec-2018

Correspondence Address:
Harshal S Sakale
HOD, Department of Orthopedics, AIIMS, Raipur, CG
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.JODP_7_18

Abstract

The incidence of hip fractures in children about 1% of total pediatric fractures. The most common cause is a high-energy trauma, such as motor vehicle accidents and falls from a height. In old cases, magnetic resonance imaging (MRI) may be needed to assess the vascularity of femoral head. Hip fractures can have deep impact on the development of hip. Vascularity of femoral head plays a vital role in the management of femoral neck fracture. The paper deals with the cited complications related to femoral neck fracture like avascular necrosis (AVN), nonunion, mal-union, and premature closure of the proximal femoral physis, leading to leg length discrepancy.

Keywords: Complications, fracture neck of femur, pediatric, vascularity

How to cite this article:
Yadav SK, Agrawal AC, Kar BK, Sakale HS, Sahoo B, Chandan RK. Pediatric fracture neck of femur. J Orthop Dis Traumatol 2018;1:11-4

How to cite this URL:
Yadav SK, Agrawal AC, Kar BK, Sakale HS, Sahoo B, Chandan RK. Pediatric fracture neck of femur. J Orthop Dis Traumatol [serial online] 2018 [cited 2023 Jun 4];1:11-4. Available from: https://jodt.org/text.asp?2018/1/1/11/248906

Introduction

Hip fractures in children are less common, with an incidence of 1% among total pediatric fracture more commonly seen in children aged more than 11 years. The most common cause is a high-energy trauma, such as motor vehicle accidents and falls from a height. High-energy trauma is associated with injuries in 13%cases. There is 30% chance of associated injuries.^[1] High-energy trauma is less commonly associated with previous bone cyst, battered baby syndrome, slipped capital femoral epiphysis, stress fracture and with children on hormonal therapy.^{[2],[3],[4],[5]}

Standard radiographs of hip and pelvis are usually sufficient to make the diagnosis. In old cases, magnetic resonance imaging (MRI) may be needed to assess the vascularity of femoral head. Hip fractures can have deep impact on the development of hip. Vascularity of femoral head plays a vital role in the management of femoral neck fracture. Complications related to femoral neck fracture are avascular necrosis (AVN), nonunion, malunion, and premature closure of the proximal femoral physis, leading to leg length discrepancy. However, treatment-related complications may also occur, such as infection and chondrolysis.

Vascularization

Blood supply to femoral head in children is different from that in adults. Because of the greater impact of blood supply on the femoral neck fracture management, it has been studied extensively and described previously.^{[6],[7],[8],[9]} Postmortem injection and microangiographic studies have provided us with insights as to how the vascular anatomy changes with age.

The vessels from the ligamentum teres contribute little to the vascularization of the femoral head until the age of 8 years. In adults, their contribution is around 20%, and it further decreases with age.

At birth, the main vascular supply to femoral head is from the branches of the medial and lateral femoral circumflex arteries, which traverse the femoral neck and predominantly supply the femoral head. With the increasing size of cartilaginous physis, these vessels diminish gradually and this blood supply is practically nonexistent from the age of 4 years. After the age of 4 years, the lateral epiphyseal vessels predominantly supply the femoral head bypassing the physeal barrier.^[10]

Two branches arise from the lateral circumflex artery, the posterosuperior (PS) and the posteroinferior (PI) branch. The medial circumflex artery anastomoses with the PS branch of the lateral circumflex artery. At the intertrochanteric groove, the medial circumflex artery ends into a retinacular system and enters the capsule. This vascular web ascends along the femoral neck to irrigate the femoral head. From the age of 3 to 4 years, the lateral PS vessels appear to predominate and supply the entire anterolateral portion of the capital femoral epiphysis.^[11] The PI and PS vessels persist throughout life and supply the femoral head. The multiple small vessels of the young child join to form a limited number of larger vessels; as a result, damage to a single vessel may lead to AVN in the older child. From the age of 14 to 17 years, the physis closes and the epiphyseal and metaphyseal vessels join to supply the femoral head and neck. In adults, there is one system that irrigates the entire femoral head.

Classification

The Delbet classification was described in 1928 and was popularized in 1929 by Colonna.^[12] It describes four different types of proximal femoral fractures in children. It is widely used to classify hip fractures in children [Figure 1].

Figure 1: Classification of pediatric fracture in femoral neck from Delbet

Click here to view

Type I

A type I fracture is a transepiphyseal fracture with or without dislocation of the femoral head. Dislocation occurs in approximately 50% of these cases. This pattern of fracture is least common; conversely, in the infant, type I fractures are more common than types II, III, and IV. Diagnosis of a type I fracture may be difficult in an infant, as the femoral head is not yet ossified. Clinically, the limb is usually positioned in flexion, abduction, and internal rotation. The differential diagnosis includes developmental dislocation of the hip and septic arthritis of the hip joint. An additional investigation such as arthrogram and MRI may sometimes be necessary to diagnose this kind of fracture.

Type II

Type II is described as a transcervical fracture, which is most common fracture pattern of all with an incidence of about 45%.^[13] Transcervical fractures are mostly due to a high-velocity accident involving direct impact. The incidence of AVN after transcervical fracture, which is directly related to initial displacement, varies from 16% to 78%.^{[13],[14],[15]}

Type III

Type III in the Delbet classification presents as a cervicotrochanteric fracture, which comprises 25%–34% of total fracture.^{[14],[15],[16]} Of all type III fractures, 25% is said to develop AVN.^{[1],[15],[17],[18]}

Type IV

Type IV is an intertrochanteric hip fracture, which represented 12% of fractures having most favorable outcome.^{[13],[15],[19]}

Treatment Options

The low incidence of these injuries may be the reason why a universal treatment protocol has not yet become available. After the first description by Cromwell^[20] in 1885, only a few reports were published until half of the 20th century, and all these patients were treated nonoperatively.^{[21],[22],[23]} Until the 1970s, it was recommended that all non- or minimally displaced fractures should be treated with cast immobilization. Closed reduction and a plaster spica cast were recommended for displaced transcervical and cervicotrochanteric fractures. A recently published article shows that fair results still can be obtained with conservative treatment; however, less adverse effects are noted when operative treatment is used.^[14]

Type I

Fixation with smooth pins is indicated for fractures without displacement^[24] as well. Conservative management with plaster spica cast, however, also remains an option. In two articles by Feigenberg et al.^[25] and Forlin et al.,^[26] results of conservative treatment with skin traction or hip spica were fair in most patients with no comparison made with operative treatment. For hip fractures with dislocation of the femoral head, a gentle closed reduction can be attempted; after which, the head is fixed with a smooth pin. If closed reduction fails, an open reduction with pin fixation is recommended using anterior approach to prevent damage to the blood supply of femoral head, which additionally decompresses the hip joint.^[27],[28] However, there is still no consensus that urgent decompression of the joint reduces the rate of complications, such as AVN.

Types II and III

Type II fractures should be treated with anatomical reduction and stable fixation to minimize the risk of late adverse effects.^[18],[29] However, good to fair results have also been reported with conservative treatment.^[25],[26] In fractures with substantial displacement, results are poor with conservative management. There is a high incidence of AVN, coxa vara, or secondary displacement.^{[28],[30],[31]} Canale and Bourland^[13] reported a decrease in complications in all nondisplaced or displaced, type II fractures, after reduction and internal fixation by pins or screws. Heiser^[31] stated that if it is necessary to bridge the physis, it is preferable to do so with smooth Kirschner wires to prevent premature closure of the physis. An anterior capsulotomy could reduce the occurrence of AVN in these fractures. When an open reduction has to be performed, the approach according to Watson-Jones is to be preferred.

Type IV

Type IV fractures results are favorable with reduction and fixation because of their inter- and subtrochanteric location.

Complications

Avascular necrosis

AVN is the most frequent and serious complication of proximal femoral fractures in children, with an incidence of 17%–59%.^[23] The chance of AVN occurring after a fracture is directly related to the amount of initial displacement, or the displacement as a result of the reduction attempts, delay in fracture treatment, type I or displaced type II fracture, and age of more than 10 years.^{[14],[32],[33]} However, there are authors who regard the type of treatment of greater importance than the type of fracture.^[34] The adjunct of decompression of the hip joint has not yet been proven to reduce the incidence of AVN.^[35] Ogden^[10] recommends repeat bone scan at 3 and 12 months. Ratliff^[36] described three types of AVN after a hip fracture. In type I, the entire femoral head is involved. Type II involves only a portion of the head. There is a zone of AVN from the fracture line to the physis in type III. The Ratcliff classification type I has the worst prognosis. The consequences of AVN can be devastating and further treatment may be needed. If internal fixation is in place when AVN develops, it should be removed after union of the fracture. Remodeling of the femoral head may occur, especially in the younger child, but may take up to 5 years.^[37] Maeda et al.^[38] proposed a non-weight-bearing regime for more than 1 year to avoid severe collapse. In a number of cases not responding to conservative treatment, management may be necessary to perform a rotational osteotomy or even a total hip replacement.

Malunion

Malunion may occur after conservative or surgical treatment of a proximal femoral fracture, which is mainly of two types, coxa vara and coxa valga. Coxa vara occurs in 20%–30% of all pediatric hip fractures. The incidence of coxa vara decreases when internal fixation is performed in fractures with displacement.^[18] Coxa vara may develop secondary to AVN, nonunion and premature physeal closure, or a combination of all above. Severe coxa vara shortens the limb causing abductor weakness that may result in early development of osteoarthritis of the hip—severe coxa vara causes shortening of lower limb which leads to abnormal forces over that particular hip while walking and leads to early OA of the Hip. Remodeling of the hip can be expected in the very young child. If the neck shaft angle is 110° or less, a subtrochanteric valgus osteotomy may be considered as suggested by Canale and Bourland^[13] and Morrissy.^[39] Coxa valga has been described in one study^[40] in which the cause of the malunion was iatrogenic.

Nonunion

Nonunion may occur in hip fractures in children with an incidence of 6%–10% of all pediatric hip fractures.^{[24],[26],[33],[41]} Primary cause of nonunion is failure to obtain, or maintain, anatomical reduction mainly in displaced fracture. In a series of 16 fractures in 16 children published by Forlin et al.,^[26] 7 nonunions were described and 6 were displaced type II fractures. Nonunion should be treated operatively, unlike AVN, as soon as possible. Valgus osteotomy usually leads to secondary union. Bone grafts can be used if necessary. In an attempt to minimize the occurrence of AVN and nonunion, Qi et al.^[42] used a vascularized greater trochanter periosteal flap transposition. They achieved excellent to good union rates in 87%. They stated that this method may accelerate union and may decrease AVN.

Premature closure of the proximal femoral physis

Premature closure of the proximal femoral physis has been reported in 5%–65% of all pediatric hip fractures. The prevalence increases when the physis is bridged by osteosynthesis material. It also increases in the presence of AVN. When crossing the physis, internal fixation is necessary, and pins are preferred to cannulated screws– In order to achieve better fixation in pediatric neck femur fracture one may have to cross the epiphysis and so pins are preferred over screws which causes less damage to the growth plate. Beaty^[43] however stated that it is more important to have stable fixation than sparing the physis. Premature closure of the physis leads to leg length discrepancy. Contralateral epiphysiodesis may be necessary when leg length difference becomes more than 2.5cm.

Conclusion

Although pediatric hip fracture is not a large burden in the orthopedic traumatology, because of precarious blood supply its behavior is notorious. The potential adverse events following these fractures are of great implication to the growing child. We should manage these fractures very aggressively. One should prefer fixation rather than conservative management, as conservative management carries higher risk for failure of reduction. Whatever approach we are using in displaced fracture, anatomical reduction must be the priority; thus, one should not hesitate doing open reduction if closed reduction is not leading to anatomical reduction. Stability of fixation device is also important, so one can cross the physis while fixation in order to make fixation stable. Frequent clinical and radiological management is also important in femoral neck management in order to identify and manage the complications as early as possible. It would also be interesting to have a standardized treatment protocol for hip fractures in children, mainly because of their low frequency and their high rate of complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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