FEMORAL NECK FRACTURES IN CHILDREN - REVIEW OF CASE SERIES

ON FIVE PATIENTS MANAGED AT THE NATIONAL ORTHOPAEDIC

HOSPITAL, DALA-KANO

NOA CONFERENCE “IFE 2012”

AUTHORS: Isa N, Salihu MN, Alada AA, Alabi IA, Arinze A and Tella AO

National Orthopaedic Hospital, Dala-Kano, Nigeria.

INTRODUCTION

• Femoral neck fractures are rare conditions in children.

• Most of the fractures result from high-energy trauma.

• Complications are associated with serious long-term morbidities.

INTRODUCTION

“ Hip fractures in children are of interest because of the frequency of complications rather than the frequency of fractures.”[1] - CANALE

AIMS/OBJECTIVES

• The aim was to evaluate the pattern of presentation, clinical outcome and complications associated with the management of paediatric femoral neck fractures at NOH, Dala-Kano.

PATIENTS AND METHOD

• The study reviewed the clinical records of paediatric patients presenting with femoral neck fractures or its complication managed at the NOH, Dala-Kano, between May 2008 and June 2012.

• Inclusion criteria:- Age ˂ 16 years at the time of injury- Complete radiographic records

PATIENTS AND METHOD• Eight patients were managed but only five met

criteria for analysis .• Delbet classification was used.• All patients had operative treatment with either

cannulated screws alone or primary osteotomy stabilized with paediatric osteotomy plate.

• Ratliff criteria was used for outcome analysis in 4 of the 5 patients, who had completed 1 year follow-up.

A. Pre-op. B. 6-weeks post-op. C. Follow-up at 1 year

A. Pre-op B. Immediate post-op C. 3-month post-op

A. Pre-op B. 6 weeks post-op C. 1-year post-op.

RESULTS• Patient Demographics:

Patient characteristics No of cases Remarks

Gender-Male-Female

41

Age range (in years) 0-5 6-10 11-15

023

Laterality of Facture-Right-Left

05

RESULTS• Mechanism of injury:

No of cases Remarks

Fall from height- storey building- tree top

12

RTA- MV-pedestrian- Motorcycle

11

RESULTS• Associated injuries:

No of cases Percentage

Facial injury 1

Blunt chest injury 2

No assoc. injury 2

RESULTSPatient Duration of

injuryMode of presentation

Delbet type

Treatment

1 10 days Painful limp II ORIF + Cannulated screws

2 3 weeks Painful limp, LLD III Osteotomy plate + screw

3 4 months Malunion, coxa vara, LLD

III Osteotomy plate only

4 7 months Malunion, coxa vara, LLD

III Osteotomy plate only

5 9 months Non-union, coxa vara, LLD

II Osteotomy plate + Screw

RESULTS• OUTCOME OF TEATMENT:

Patient Delbet type Complications Ratliff outcome

1 II - Good

2 III - -

3 III Surgical site infection

Good

4 III Premature physeal closure (LLD-6cm)

Fair

5 II Avascular necrosis

Fair

DISCUSSION

• Paediatric femoral neck fractures are uncommon.

• The average incidence, worldwide is ˂ 1% of all paediatric fractures [1,2,3,4,5].- May be higher in our environment [6].

• Most cases result from high-energy trauma.

DISCUSSION

• The presence of physis and vascular peculiarities make paediatric femoral neck fractures an important clinical entity.

• The risk of severe complications like AVN and growth arrest, make prompt treatment of paediatric femoral neck fractures a priority.

DISCUSSION

• Delbet classified these fractures into 4 types- Type I : Transepiphyseal (5-10%)- Type II : Transcervical (50%)- Type III : Cervico-trochanteric or Basal (35%)- Type IV : Intertrochanteric (10-15%)

• Our study revealed more of type III (3 patients).

DISCUSSION

• Three of our patients, presented late with complications – malunion, nonunion and coxa vara.

• Initial TBS involvement in 3 patients - Remaining 2 cases were referrals

• We offered 4 of our patients primary osteotomy due to the mode of presentation.

DISCUSSION• Of all the complications reported in the

literature, AVN is the most common and most devastating [7,8].

• Quick et al [9], reported an average incidence of 6-53% for AVN in paediatric femoral neck fractures.

• In our study, AVN occurred in 1 patient, and risk factors identified include:- Type of fracture and displacement- Late presentation.

DISCUSSION

• A case of premature physeal closure occurred, with worsening LLD at follow-up.

• Residual coxa vara also seen in 2 patients.• Other complication seen was surgical site

infection in 1 patient.

DISCUSSION• Ratliff criteria:

CONCLUSION

• The clinical outcome of our study was mainly influenced by late presentation.

• Malunion, Nonunion and coxa vara were seen as primary complications rather than secondary.

• Based on Ratliff criteria, at the end of 1 year, 2 of our patients had satisfactory outcome.

MANY THANKS

REFERENCES

• 1) Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg Am. 1977 Jun.;59(4):431–443.

• 2) Bali et al. Paediatric Femoral Neck Fractures. Clinics in Orthop. Surg. 2011; Vol.3 No. 4; 302-308.

• 3) Arora et al. Outcomes in Paediatric Femoral Neck Fractures. Delhi J. of Orthop. 2004; 1: 25-49.

• 4) Bimmel et al. Paediatric Hip Fractures: A systematic review of incidence, treatment options and complications. Acta Orthop. Belg. 2010; 76; 7-13.

• 5) Feng-Chih Kuo et al. Complications of paediatric hip fractures. Cnang Gung Med J. 2011; Vol.34, No. 5

REFERENCES

• 6) Nwadinigwe et al. Fractures in children. Nigerian J of medicine. Jan-Mar 2006; Vol. 15, No. 1,

• 7) Ratliff. Fractures of the neck of the femur in children. J Bone Joint Surg Br. 1962;44-B:528–542.

• 8) Pedro et al. Nonunion of fractures of the femoral neck in children. J Child Orthop. 2008; 2: 97-103

• 9) Quick TJ, Eastwood DM. Pediatric Fractures and Dislocations of the Hip and Pelvis. Clin Orthop Relat Res. 2005;432:87–96