Controversies in the management of pediatric neck femur fractures- a systematic review

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.

Epidemiology and demographics of pediatric proximal femur fractures in Türkiye: results from a government-based health registry

We evaluate the epidemiology and incidence of pediatric proximal femur fractures, treatment trends among different hospital levels, and complication rates among different treatment modalities by examining a national health registry in Türkiye. The health records of individuals aged ≤16 years admitted to public, private, and university hospitals were collected via the e-health database of the Turkish Ministry of Health. A total of 2388 children treated for proximal femur fractures from 2016 to 2021 with at least 2 years of follow-up were included in the study. While 2033 (85.1%) patients were treated with closed reduction and spica casts, 355 (14.8%) were operated on. Mean age was 8.603 ± 5.11 years. Male incidence was 2-fold greater compared to female patients (36.4% female and 63.6% male patients; P <  0.001). The frequency of cases was significantly increased in the age groups of 3-4 and 13-16 years. Comorbidities causing limited ambulation were detected in 6.5% of all cases, and 163 (8.0%) patients in the conservative group and 98 (27.6%) patients in the surgery group had at least one complication. The incidence was 0.45 per 100 000 children aged ≤16 years. This study reports the largest patient cohort to date, providing evidence on the epidemiology and incidence of pediatric proximal femur fractures using health registry data. We have found that the most common treatment modality for proximal femur fractures is closed reduction with spica casts. The rate of avascular necrosis is similar among patients treated surgically and those treated conservatively.

Management of a Proximal Femoral Central Physeal Bar in a 3-Year-Old Child Using a Novel Surgical Technique: A Case Report

CASE

We present a proximal femoral central physeal bar secondary to femoral neck fracture management, in a 3-year-old boy. He presented with progressive femoral neck deformity and limb length discrepancy. He was managed with a novel technique of bar resection by drilling and polymethylmethacrylate interposition. After 5 years of follow-up, the hip score by Ratliff criteria was good.

CONCLUSION

Screw penetration across physis during management of femoral neck fracture can cause growth arrest in a young child. Our technique is useful when physeal bar is central and linear. It can allow sufficient growth and remodeling to restore a near-normal hip both radiologically and clinically.

Traumatic injuries of the immature hip and pelvis

PURPOSE OF REVIEW

The pelvis and hip account for 0.3--4% of fractures of the immature skeleton, and generally result from high energy trauma. These fractures range in severity from apophyseal avulsions to complete disruptions of the pelvic ring. The purpose of this article is to review the presentation, diagnosis, treatment and complications of these injuries in order to inform clinicians involved in their management. There is a lack of evidence-based management protocols for fractures of the immature pelvis largely due to their rarity and lack of robust scientific literature on the topic.

RECENT FINDINGS

Computed tomography/MRI is essential as up to 30% of pelvis and 70% of acetabular fractures are not identified on initial radiographs. A sub-optimal outcome is common in unstable fractures treated conservatively and adequate reduction and surgical stabilization is often required to avoid long-term morbidity.

SUMMARY

A coordinated approach involves resuscitation and temporary stabilization with planned definitive fixation. It is generally accepted that these injures should be managed in paediatric trauma centres. Whilst injuries vary in pattern and severity, we present an overview that considers the evaluation and treatment of the paediatric patient with pelvic and hip fractures to ensure that these injuries are identified promptly and treated by surgeons familiar with contemporary management algorithms.

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.

A Comparative Study between Proximal Femoral Locking Plate and Multiple Cannulated Screws for Fixation of Femoral Neck Fractures in Young Adults

OBJECTIVE

To compare the clinical effect of proximal femoral locking plate (PFLP) versus multiple cancellous screw (MCS) for FNF.

METHODS

FNF patients were treated with the PFLP implant or multiple cancellous screws (MCSs). Patient has been followed up for at least 12 months after surgery nonunion, and the occurrence of complications, femoral neck shortening, fracture healing time, and Harris hip score were recorded and compared.

RESULTS

77 FNF patients were treated with the PFLP (36 patients) or MCS (41 patients). The sex, age, side of the injured limb, type of Garden fracture, time from injury to surgery, and fracture healing time of two groups patients were comparable. The operation time and intraoperative blood loss in the PFLP group were worse than those in the MCS group. Two patients with the PFLP (5%) and nine patients (21%) with the MCS experienced cut out of the lag screw or avascular necrosis of the femoral head or nonunion and received hip replacement. However, the number of fluoroscopies in the PFLP group was significantly lower than that in the MCS group. Additionally, the femoral neck shortening and Harris hip score were all strongly better in the PFLP group than in the MCS group.

CONCLUSIONS

Compared with the MCS, PFLP treatment for FNF in young adults can decrease the fluoroscopy times, improve hip functional recovery, and reduce the complications rate and femoral neck shortening.

Management of Postoperative Infection After Fixation of a Delbet Type III Pediatric Femoral Neck Fracture: A Case Report

CASE

A pediatric male patient sustained a postoperative infection of the femoral neck after open anatomic reduction and internal fixation (ORIF) of a Delbet type III femoral neck fracture. Treatment included surgical intervention with antibiotic Steinmann pins incorporated into an external fixator to provide stability to the femoral neck. At the 27-month follow-up, films showed complete healing with a 1.67-cm leg length discrepancy, treated with a 1-cm shoe lift.

CONCLUSION

There is insufficient literature for the treatment of postoperative infection after ORIF in a pediatric patient. We present a successful treatment method for treating an infection while sustaining the stability of the femoral neck.