Courtesy: Dr Ashok Shyam, Dr. Alvin Crawford, Ortho TV

 

Pediatric Femoral Neck Fractures

Overview

• Rare injuries accounting for approximately 1% of pediatric orthopedic fractures
• Usually caused by high-energy trauma
• Trivial trauma should raise suspicion for:
  • Pathological fracture
  • Insufficiency fracture

---

Common Pathological Causes

• Unicameral bone cyst
• Chondroblastoma
• Osteosarcoma

---

Epidemiology

• More common in boys
• Incidence in girls is increasing

---

Delbet Classification

Delbet classification

---

Type I – Transphyseal Fracture

Features

• Fracture through the proximal femoral physis
• May be associated with hip dislocation

Important Point

• Highest risk of avascular necrosis (AVN)

---

Type II – Transcervical Fracture

Features

• Fracture through the femoral neck

Clinical Importance

• High risk of AVN
• Requires:
  • Anatomical reduction
  • Stable internal fixation

---

Type III – Cervicotrochanteric Fracture

Features

• Fracture at the base of the femoral neck

Complications

• Coxa vara
• Non-union

AVN Risk

• Lower than Type I and II

---

Type IV – Intertrochanteric Fracture

Features

• Best prognosis among Delbet fractures
• Lowest AVN risk

Treatment

• Aggressive fixation still recommended

---

Type V – Pathological Fracture

Causes

• Unicameral bone cyst
• Chondroblastoma
• Osteosarcoma

---

Clinical Features

Symptoms

• Severe hip pain
• Inability to bear weight

---

Limb Position

• External rotation
• Shortening

---

Differential Diagnosis

Consider:

• Developmental dysplasia of the hip
• Septic arthritis
• Slipped capital femoral epiphysis

---

Most Important Complications

---

1. Avascular Necrosis (AVN)

Avascular necrosis of femoral head

Risk Increases With

• Fracture displacement
• More proximal fracture location

AVN Risk Order

Type I > Type II > Type III > Type IV

---

2. Coxa Vara

Causes

• Fracture collapse
• Inadequate fixation

---

3. Non-union

• More common in displaced fractures
• Associated with unstable fixation

---

4. Premature Physeal Closure

Consequences

• Limb length discrepancy
• Growth disturbance

Note

• Sometimes acceptable if alignment is maintained

---

5. Chondrolysis

• Progressive cartilage loss and joint stiffness

---

Management Principles

---

Pediatric Femoral Neck Fracture Is an Emergency

• Early treatment improves outcome
• Delay increases risk of AVN and complications

---

Reduction Principles

Goal

• Anatomical reduction

---

Preferred Sequence

1. Closed reduction initially
2. Open reduction if anatomical alignment cannot be achieved

---

Fixation Principles

Stable Internal Fixation Is Essential

Common Fixation Methods

---

Additional Technical Points

• Anti-rotation pins improve stability
• Stable fixation prevents redisplacement
• Poor fixation increases complication risk

---

Capsulotomy / Decompression

Possible Benefits

• Reduces intracapsular pressure
• May decrease risk of AVN

Important Note

• Exact role remains controversial

---

Important Surgical Principles

• Achieve anatomical reduction
• Ensure rigid fixation
• Prevent rotational instability
• Confirm stable alignment intraoperatively

---

Counseling Parents

Families should be warned about potential long-term complications:

• AVN
• Limb length discrepancy
• Coxa vara
• Need for future surgery

---

High-Yield Exam Pearls

• Most important complication: AVN
• Highest AVN risk: Delbet Type I
• Treatment goal:
  • Anatomical reduction
  • Stable fixation
• Best prognosis: Intertrochanteric fractures (Type IV)
• Trivial trauma should prompt evaluation for pathological fracture

---

Quick Summary Table