Long-term follow-up of children with femoral neck fractures

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

Purpose

To review controversies systematically in the management of pediatric neck femur fracture from the literature and to develop consensus for the optimum management.

Methods

Authors searched literature by using keywords of pediatric neck femur fracture, proximal femur fracture, complications, management by following PRISMA guidelines. A common dilemma was listed.

Results

Age, mechanism of injury, fracture type, presentation, treatment method, implant, and nature of complications were compared. Inference from recent literature was extracted for optimum management.

Conclusion

Immediate anatomical reduction with stable fixation must be accomplished. Complications continue to happen despite the best efforts and a longer follow-up is important.

Retrospective analysis of 35 pediatric femoral neck fractures

OBJECTIVE

Pediatric proximal femur fracture is extremely rare trauma comparing to other fractures. The proximal femur fracture is 1% of all pediatric fractures. The aim of current study is to compare the incidence of early complications and outcomes of pediatric proximal femur fractures regarding fracture types retrospectively.

DESIGN

Our study includes 35 cases which are criticized by Delbet classification system, modalities of treatment, duration of waiting for surgery, duration of follow-up and also complications. Our inclusion criteria are age below 16 years old, proximal femur fractures with no evidence of tumoral, romathologic and methabolic conditions. Age, sex and surgery type (open-closed) were noted, and the data were statistically assessed. Assessment of the final outcome was made at the last follow-up visit using the Ratliff's method.

RESULTS

The mean of age of patients in our study is 9.5 ± 5.06 years. The average follow-up was 25.6 ± 13.2 months. 15 patients (42.9%) are type 2 Delbet fracture, 5 patients (14.2%) are Delbet type 3 and 15 patients (42.9%) are Delbet type 4 fracture. Using the Ratliff's method, 25 patients (71.4%) had satisfactory outcomes. Ten patients (28.6%) had unsatisfactory outcomes. The complications as AVN, coxa vara and premature closure of physis, non-union and postoperative infections have been detected in this study. AVN was seen in four (11.4%) patients. In addition, coxa vara was seen in six (17.2%) patients.

CONCLUSION

Pediatric femoral neck fractures are extremely rare fractures and can be treated with low complication rates in cases with early treatment and anatomic reduction.

Total Hip Arthroplasty for the Sequelae of Femoral Neck Fractures in the Pediatric Patient

Although rare, total hip arthroplasty (THA) may be indicated in pediatric patients with degenerative changes of the hip joint after previous trauma. To illustrate management principles in this patient population, this study describes the case of a 15-year-old female who sustained bilateral femoral neck fractures after a generalized tonic-clonic seizure, an atypical, low-energy mechanism for this injury. These fractures were not diagnosed until 14 weeks after the seizure episode, at which point they had progressed to nonunion on the left side, malunion on the right side, and degenerative hip joint changes were developing bilaterally. Bilateral THA was ultimately performed, and the patient had favorable outcomes at 1 year postoperatively. In determining the optimal management strategy for such patients, a multidisciplinary approach should be used, with input from the patient’s family, pediatrician, pediatric endocrinologist, pediatric orthopaedic surgeon, and adult reconstruction surgeon. From a surgical standpoint, this report highlights the importance of selecting the appropriate bearing surfaces, broaching technique, mode of implant fixation, and implant features when performing THA in the active pediatric patient.

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.

Management of Pediatric Femoral Neck Fracture

In the pediatric population, femoral neck fracture is a relatively uncommon injury with a high complication rate, despite appropriate diagnosis and management. The anatomy and blood supply of the proximal femur in the skeletally immature patient differs from that in the adult patient. Generally, these fractures result from high-energy trauma and are categorized using the Delbet classification system. This system both guides management and aids the clinician in determining the risk of osteonecrosis after these fractures. Other complications include physeal arrest, coxa vara, and nonunion. Multiple fracture fixation methods have been used, with the overall goal being anatomic reduction with stable fixation. Insufficiency fractures of the femoral neck, although rare, must also be considered in the differential diagnosis for the pediatric patient presenting with atraumatic hip pain.

Pediatric Hip Fractures in California: Results from a Community-Based Hip Fracture Registry

CONTEXT

Hip fracture registries offer an opportunity to identify and to monitor patients with rare conditions and outcomes, including hip fractures in pediatric patients.

OBJECTIVE

To report patient demographics and surgical outcomes of pediatric patients treated surgically for hip fractures in a large integrated health care system.

DESIGN

Pediatric patients (< 21 years old at the time of fracture) with hip fractures were identified between 2009 and 2012 using our health care system's hip fracture registry.

MAIN OUTCOME MEASURES

Patient characteristics, type of fracture, surgical treatment, and short-term complications.

RESULTS

Among 39 patients identified, 31 (79.5%) were male, and the median age was 15 years old (interquartile range: 11-17 years). Most patients were Hispanic (n = 17, 43.6%) or white (n = 14, 35.9%). There were 8 patients (20.5%) with 15 comorbidities. Delbet Type IV (intertrochanteric) fractures were the most common fracture type (n = 22, 56.4%), and fixation method was equally distributed between intramedullary, screw and sideplate, and screws (n = 12, 30.8% for each). Most surgeries were performed by medium-volume surgeons (n = 22, 56.4%) at medium- and high-volume hospitals (n = 37, 94.9%). Three 90-day readmissions (7.7%), 1 infection (2.6%), 1 malunion (2.6%), and 1 revision (2.6%) were observed in this cohort during the study period.

CONCLUSION

In our series using registry data, hip fractures younger than age 21 years were more common in boys and Hispanic patients. Intertrochanteric fractures (Delbet Type IV) were the most frequently observed type in our community-based hip fracture registry. Short-term complications were infrequent.

Overgrowth of the femoral neck after hip fractures in children

Background

Overgrowth after pediatric femoral shaft fractures is well documented; however, overgrowth of the femoral neck after hip fractures has not been especially reported previously. The purpose of this study was to evaluate the incidence and characteristics of femoral neck overgrowth after hip fractures in children.

Methods

From January 1990 to December 2012, there were 30 consecutive patients with pediatric hip fractures. We retrospectively reviewed the medical record of all the patients, including age at injury, gender, injury mechanism, fracture type, methods of treatment, time to bony union, and complications. The functional outcome was evaluated by Ratliff’s criteria. The radiography of the pelvis was performed in controlled positions of abduction and external rotation. The length of the femoral neck was measured by two observers. The overgrowth of the femoral neck was defined as lengthening more than 3 mm in comparison with the uninjured hip.

Results

At a mean follow-up of 4.9 years (range 2–8 years), 12 patients (40 %) had an overgrowth of the femoral neck. The average overgrowth of the femoral neck was 6.2 mm (range 3.2–8.5 mm). The patients with femoral neck overgrowth were younger (p = 0.0002), have lower rate of avascular necrosis of the femoral head (p = 0.0006), and have better functional outcome (p = 0.0026).

Conclusions

Our results provide evidence that overgrowth of the femoral neck following hip fractures may occur in children and the overgrowth phenomenon in the femoral neck was a predictor of good outcomes after treatment.

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.

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.

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.

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.

Fractures of the head and neck of the femur in children: an outcome study

Fractures of the head and neck of the femur in children are very rare, occurring only after a high-velocity trauma, e.g. a fall from a height. This analysis shows the clinical course of traumatic femoral head and neck fractures in paediatric patients. Predisposing factors for poor outcome or fracture complications, such as non-union or femoral head necrosis, are described. Between 1993 and 2006, 16 paediatric patients with proximal femoral fractures were treated at the Level One Trauma Centre of the Medical University of Vienna. The minimum follow-up was two years. Inclusion criteria were age less then 16 years, intact growth plate and a proximal femoral fracture according to the classification by Delbet and Colonna. Exclusion criteria were pathological fractures or fractures of the subtrochanteric region (6/16). Ten patients met the inclusion criteria. Two patients were lost to follow-up. Therefore eight patients were included in the study. All patients except one were operated upon within 48 h after the injury ("primary") and healed without further complications. A single case was managed by "secondary" surgical treatment, two weeks after the initial trauma resulting in femoral head necrosis that healed without any subjective complaints. This case series confirms the importance of early surgical fixation of proximal femoral fractures in paediatric patients. An operative intervention later then 48 h after the initial trauma may increase the risk of complications such as femoral head necrosis, particularly in Delbet type I fractures (traumatic slipped capital femoral epiphysis).

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.

Pediatric femur neck fractures: a retrospective analysis of 39 hips

PURPOSE

The aim of this retrospective study was to analyze the radiological and clinical results of pediatric femur neck fractures.

METHODS

This study included 39 children (mean age 11.1, range 4 to 16 years) who had a femur neck fracture and had at least one year of complete follow-up. The most common etiological factor was traffic accident and the most common associated skeletal injury was pelvis fracture.

RESULTS

According to Delbet's classification system, there were no type I (transepiphyseal) fractures and 21 type II (transcervical), 14 type III (cervicotrochanteric), and four type IV (intertrochanteric) fractures. The mean follow-up was 3.4 (1-9.5) years. A satisfactory outcome according to Ratliff's radiological and clinical criteria was obtained in 28 (72%) hips. Avascular necrosis (AVN) of the femoral head was seen in 11 (28%) hips and the rate of satisfactory outcome was significantly higher in hips without AVN than in hips with AVN (P < 0.001). Transcervical fractures had the worst outcome (P = 0.014) and the highest rate of AVN (P = 0.077) when compared with cervicotrochanteric and intertrochanteric fractures. No significant correlation was found between both the outcome and development of AVN and age, gender, laterality, amount of fracture displacement, treatment time, and the type of reduction (open/closed) (P > 0.05).

CONCLUSIONS

It has been concluded that the development of AVN primarily influences the outcome in pediatric femur neck fractures and that fracture type is essentially correlated with the development of AVN and outcome.

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 femoral neck in children: long-term follow-up in 62 hip fractures

In this retrospective study, we evaluated the characteristics of 103 femoral neck fractures in 102 children seen our department between 1978 and 1994. In order to evaluate the correlation between the chosen procedure and complication risks, we further reviewed the late treatment results of 62 fractures in 61 children of the series whom we had followed for a minimum of 8 years. The ages of these children at the time of injury ranged from 2 to 14 years (average 10.2 years). Sixty-three hips were available for clinical and radiographic follow-up at a minimum of 8 years (mean 14 years). Overall, 67.2% radiologically good results were obtained. Complications were coxa vara in five (8%), avascular necrosis in nine (14.5%), premature epiphysis fusion in five (8%), coxa valga in two (3.2%), non-union in one (1.6%), limb shortening in seven (11.3%), and arthritic changes in two (3.2%). Our long-term follow-up revealed that the type of treatment influences the complication rate more than do the characteristics of the fracture itself, and that the end result cannot be satisfactorily determined until after physeal closure.

Complications associated with surgically treated hip fractures in children

Although hip fractures make up less than 1% of all children's fractures, they commonly produce late complications such as avascular necrosis, non-union, coxa vara, and premature physeal closure. A retrospective review of 17 patients with a mean age of 11 years (range, 7-14) and with a mean follow-up of 6 years (range, 2.5-12) who underwent open reduction and internal fixation for hip fractures was performed. There were 10 transcervical and five cervicotrochanteric fractures, one transepiphyseal fracture, and one intertrochanteric fracture. A total of 25 operations were performed. Overall, the complication rate was 59%, with some patients having more than one complication. Seven patients healed without any complications or sequelae. In the remaining 10 patients, the complications were avascular necrosis (nine patients), coxa vara (eight patients), premature physeal closure (seven patients), non-union (four patients), and chondrolysis (one patient). Avascular necrosis, non-union, and chondrolysis were associated with a poor outcome. At final follow-up, the results were assessed using Ratliff's criteria and included seven patients with good, six with fair, and four with poor outcome.

Femoral neck fractures

Femoral neck fractures in the geriatric patient continue to represent a therapeutic challenge. Despite advances in surgical techniques and medical care, the risk of nonunion and osteonecrosis after fixation have not changed appreciably in the last 50 years. Considerable debate continues to occur with respect to the relative merits of internal fixation versus arthroplasty. The relative benefits and complications of unipolar and bipolar hemiarthroplasty, as well as total hip replacement, continue to be poorly understood. The next decade will bring advances in the prevention and treatment of osteoporosis that may finally decrease the incidence of these fractures. Advances in the use of bone graft substitutes may finally improve the outcome of internal fixation.

Treatment of osteonecrosis in the hip of pediatric patients by free vascularized fibular graft

The purpose of the current study was to review the demographics and etiologies of symptomatic femoral head osteonecrosis in the pediatric and adolescent population and to assess the results of treatment using free vascularized fibular grafting. A group of patients with femoral head osteonecrosis who were treated with free vascularized fibular grafting was reviewed. Patients who were studied were 18 years of age or younger at the time of surgery. Records were examined for demographic data, etiology of osteonecrosis, stage of the disease at time of surgery, and results of treatment including preoperative and postoperative Harris hip scores. Eighty-two pediatric and adolescent patients with osteonecrosis of the femoral head underwent 90 free vascularized fibular grafting procedures. Fifty patients (54 hips) who have been followed up at least 2 or more years (average, 4.3 years) constituted the study group. At the last followup, total hip arthroplasty was performed in seven hips (seven patients) and hip fusion was performed in one hip (one patient). The average Harris hip scores in patients who did not undergo total hip arthroplasty improved from a preoperative average of 55.3 points to 90.2 points at the latest followup. Treatment of patients with osteonecrosis with free vascularized fibular grafting resulted in a lower rate of conversion to total hip arthroplasty or fusion (16%) in pediatric and adolescent patients when compared with conversion to total hip arthroplasty in adults (25%). The quality of life as evidenced by the increased Harris hip scores was improved significantly in this group of pediatric and adolescent patients.

Salter-Harris type II fractures of the capital femoral epiphysis

Salter-Harris type II fractures of the capital femoral epiphysis have not been previously documented. The authors have treated three patients who sustained four such fractures. One child had a recurrent fracture two years after the first had healed satisfactorily. Two fractures were treated by spica cast immobilization, one fracture by closed reduction and internal fixation, and the other fracture healed without treatment. No patient developed avascular necrosis or other complications. Two of the children had an association with idiopathic slipped capital femoral epiphysis. An etiologic relationship with slipped capital femoral epiphysis, if any, is uncertain.

Delayed separation of the capital femoral epiphysis after an ipsilateral transcervical fracture of the femoral neck

A displaced transcervical fracture of the femoral neck in a three-year-eight-month-old boy was fixed with two screws, which did not cross the growth plate. When he resumed walking five weeks after the injury, a delayed separation of the capital femoral epiphysis occurred. The displaced epiphysis was reduced and fixed with three unthreaded pins. In spite of disruption of the femoral neck at two sites, avascular necrosis of the femoral head did not occur. This was confirmed by two sequential isotope scans. Delayed epiphyseal separation after the femoral neck fracture and the preservation of the vascularity of the epiphysis in this case are both very unusual.

Long-term outcome in children with fractures of the proximal femur after high-energy trauma

BACKGROUND

Fractures of the femoral head and neck in children have a risk of severe complications, especially femoral head necrosis. We performed a long-term follow-up study of patients treated at our institution.

METHODS

Patients were reexamined at least 3 years after trauma and were included if they were younger than 17 years old at the time of injury, if there was no history of previous fracture, and if there was no history of underlying bone disease. Fractures were classified according to Delbet, and outcome was graded according to Ratliff. Anterior capsulotomy was not performed, and stabilization devices were placed short of the epiphysis except for type I fractures.

RESULTS

Of 32 patients, 28 were reexamined. Among these patients, the mean age at the time of injury was 11.8 years and the mean follow-up time was 11.1 years (range, 3-21 years). There were 3 patients with type I fractures, 8 patients with type II fractures, 12 patients with type III fractures, and 5 patients with type IV fractures. Thirteen patients had Injury Severity Scores > 18. At last follow-up, 20 patients presented with good function, 5 with fair outcome, and 3 with poor results; all of the latter suffered type I fractures. Eighteen patients had no restrictions in activities of daily living or during sports activities. In six other patients, the inability to participate in sports was attributable to head trauma, amputation, or peripheral neurologic damage.

CONCLUSION

We found favorable long-term outcome in type II to type IV fractures. In these patients, restrictions of function were usually caused by other associated injuries. All patients with type I fractures presented with poor outcome secondary to their proximal femoral fractures, and not because of other associated injuries. Type I fractures during childhood and adolescence represent an unsolved problem.

'Natural' healing of hip fractures in childhood

Twenty intracapsular fractures of the femur in children below 14 years of age were reviewed. Gentle reduction was performed successfully in the displaced fractures. Close apposition of fracture fragments was maintained in all cases with skeletal traction for a time depending on the patient's age, the displacement and the appearance of bridging callus along the medial cortex of the femoral neck. Periosteal healing was evident in the displaced fractures, even in cases of severe ischaemic necrosis. This paper presents this phenomenon of initial external callus repair, not previously reported in the literature, which indicates the existence of functional periosteum of the femoral neck in children.

Types and complications of femoral neck fractures in children

This multicenter collaborative study was undertaken to review the types and complications of femoral neck fractures in children. It is a retrospective clinical and radiological review of 108 femoral neck fractures. Cases originated from four different pediatric hospitals. All the patients had plain radiographs. Fractures occurred at all ages (one day to 18 years), and 63% of the patients were boys. Forty-nine fractures were traumatic; 37 were pathologic, 19 were insufficiency fractures; and three were fatigue fractures. Unless the underlying bone was abnormal, significant high velocity trauma, fall from a height or other severe violence was required to fracture the femoral neck. A unicameral bone cyst was the underlying lesion in 40% of pathologic femoral neck fractures and malignancy in 35%. Osteoporosis as in myelodysplasia, osteogenesis imperfecta and from other causes was responsible for 52% of insufficiency fractures. Because of the unique osseous and vascular anatomy of the femoral head and neck in the growing child, these fractures have a high incidence of complications. Complications included avascular necrosis 13%, premature closure of the epiphyseal plate 12%, varus deformity 8.3%, and nonunion 3.7%. Unless there is a clear history of significant violence, a cause for a femoral neck fracture should be sought, e.g. an underlying bone lesion or a metabolic bone disease. These fractures are rare, but are serious injuries since their complications may lead to a life-long disability.

Management of childhood femoral neck fractures

Forty-three children with displaced transcervical femoral fractures were reviewed at a mean follow-up of 7.2 years and results were assessed using Ratliff's criteria. Of 22 patients treated by internal fixation alone, 10 had good, 6 had fair and 6 had poor results. The results in 21 children treated by internal fixation along with primary transverse intertrochanteric undisplaced osteotomy were: 14 good, 5 fair and 2 poor, but none improved to a statistically significant level (P = 0.139). However, the osteotomy improved the fracture union significantly and no delayed union or non-union was noted in this group (P = 0.05). There were no complications related to the osteotomy itself.

Evaluation of an interfragmentary compression system for the repair of equine femoral capital physeal fractures

Femoral neck and proximal epiphyseal lengths were measured in 37 femurs from 19 cadaver foals that were 1 day to 12 months old to determine the applicability of a human interfragmentary compression system to equine femoral capital physeal fractures. Because components of the implant system are available only in fixed sizes, its use was possible in foals older than 5 weeks of age, but not in younger foals. The 135 degree angle plate conformed best to the equine femur. Femoral capital physeal fractures were created surgically and repaired with the implant system in three foals. Fracture stability was evident clinically and radiographically in all three foals until euthanasia at month 3. At necropsy, the treated femurs were 4, 8, and 27 mm shorter than their mates. Epiphyseal viability was verified in all three foals by tetracycline deposition and new appositional bone growth comparable with that in the contralateral control epiphyses. The treated capital physis was open but reduced in thickness in one foal, disorganized in one foal, and closed in one foal. Fixation by compression with the implant system resulted in stability sufficient for fracture healing and maintenance of epiphyseal viability, although it was associated with reduced longitudinal femoral growth.

Femoral capital physeal fractures in 25 foals

The medical records of 25 horses 1 year of age or younger affected with femoral head and neck fractures during an 18 year period were reviewed. Each fracture involved the capital physis. The foals were 11 days to 12 months of age (mean, 5 months). No femoral capital physeal fractures occurred in horses older than 1 year of age during the same period. The history in each case included acute onset of severe unilateral hindlimb lameness, 3 hours to 2 months (mean, 12 days) before presentation. Injuries observed were violent falls, struggles, and kicks. Crepitation, swelling, pain with manipulation or palpation or both, and apparent fracture fragment displacement were inconsistently noted. Tentative clinical diagnoses were confirmed by radiography in 24 foals and by necropsy alone in one foal. Twenty-one foals were euthanatized due to poor prognosis. One foal sent home for stall rest was lost to follow-up. Surgical repair was attempted in three foals. Two fractures were repaired with multiple intramedullary pins and the foals were euthanatized within 2 weeks due to surgical failure and, in one case, contralateral limb breakdown. The third fracture was repaired with a compressing screw and plate device; the animal was pasture sound at month 20.

Hip fractures in children. A long-term follow up of 17 cases

Late results (average 18 years posttrauma) after hip fractures in 17 children are reported. The average age at the time of fractures was 8.5 years (range 2 to 15 years). The treatment was conservative for undisplaced or slightly displaced transcervical and cervicotrochanteric fractures (Delbet's Type II and III) as well as for intertrochanteric fractures (Delbet's Type IV). The overall complication rate was 25%. Avascular necrosis of the femoral head was seen in two hips, premature epiphyseal closure with leg shortening in two cases, and a coxa vara in one hip. These complications only had resulted in few symptoms at follow up.