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TRAUMATOLOGY Table of Contents   
Year : 2006  |  Volume : 40  |  Issue : 4  |  Page : 228-231
Unstable femoral neck fractures in children - A new treatment option


1 Department of Orthopaedics, SN Medical College, Agra, India
2 Department of Orthopaedics, Maulana Azad Medical College, New Delhi, India

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   Abstract 

Background : Femoral neck fractures in children are an uncommon but difficult situation. The aim of our study was to evaluate clinical results of closed reduction internal fixation and primary valgus osteotomy fixed with a tension band wire loop in high angled pediatric femoral neck fractures.
Methods : In a prospective nonrandomized study conducted at 2 centres, sixteen children and adolescents with a Pauwel type 2/3 fracture neck femur were taken as participants. The femoral neck fractures were stabilized using closed reduction and internal fixation (6.5 mm noncannulated screw) and a primary valgus osteotomy fixed with a tension band wire loop preferably within 24-36 hours of injury. Patients were evaluated to determine complications, clinical and radiological outcome.
Results : At a mean post operative follow up of 5 years, union was achieved in all cases. Three patients had AVN and one developed coxavara. Results were evaluated using IOWA hip scores. Thirteen patients had an excellent result while 3 patients had a good result.
Conclusion : Use of this technique holds promise in treating these difficult unstable fractures. Although results from a larger series are still awaited yet the use of this technique can safely be extended to stable fractures also, to minimize the incidence of complications as nonunion and AVN.

Keywords: Fracture neck femur; Children, Tension band wiring; Valgus osteotomy.

How to cite this article:
Pruthi K K, Maini L, Pruthi K. Unstable femoral neck fractures in children - A new treatment option. Indian J Orthop 2006;40:228-31

How to cite this URL:
Pruthi K K, Maini L, Pruthi K. Unstable femoral neck fractures in children - A new treatment option. Indian J Orthop [serial online] 2006 [cited 2019 Apr 23];40:228-31. Available from: http://www.ijoonline.com/text.asp?2006/40/4/228/34500

   Introduction Top


In children the dense bone of femoral neck is surrounded by a strong periosteum and a high energy force must be applied before breaking it[1]. This explains the rarity of femoral neck fractures in children less than 1% of all fractures. But in the northern part of our country, a large number of children sustain this fracture because of fall from trees and poorly constructed roof tops where they sleep on hot summer nights.

The classification system originally described by Delbet and popularized by Colonna is most commonly used for these fractures[2]. A large number of these fractures fall into Pauwel type 2 and 3 especially when the injury is due to a fall from height and these fractures if not adequately stabilized are prone to develop complications as nonunion, coxavara, avascular necrosis and premature epiphyseal closure.

Proper primary treatment of this potentially hazardous fractures is the key to a successful outcome, a fact which has been illustrated in recent studies[3],[4],[5]. The aim of our prospective study is directed towards finding a solution, which is technically easy and has minimum complication rates.


   Material and methods Top


Over a 7 year period (1998-2005) we conducted a joint prospective nonrandomized study at two hospitals. The overall patient population comprised of 42 paediatric (age less than 16) femoral neck and intertrochanteric fractures. Out of these only 16 fractures were chosen for the stated surgical modality. Our entire study focuses on these 16 patients only. The criterion for selection in the study group was a Pauwel type 2 or type 3 femoral neck fracture admitted within 24-48 hours after injury. Pauwels classification has been never used in pediatric fractures but in our study we have used it to select the high angled, vertically oriented femoral neck fractures. In these cases there are tremendous amount of shear forces acting on the fracture site, which makes them extremely prone to complications as nonunion and avascular necrosis.

Eight patients were of Pauwel type 2 and I of Pauwel type 3. According to Delbet and Colonna classification there were 9 transcervical and 7 cervicotrochantric fractures. Ten of these fractures occurred in males and 6 in females. Seven patients belonged to 4-7 year age group and 9 patients were between 8-15 years.

The etiological factors were fall from height in 10 children, automobile accidents in 5 and a simple fall in one. All patients were operated upon within 24-36 hours of injury. Six patients had associated injuries like fracture clavicle[6],femoral shaft fracture[3], contralateral subtrochantric fracture[6], and fracture supracondylar humerus[3]. These fractures were managed on their merits.

Principles of operative technique were early decompression of capsular distention, closed reduction of fracture and valgus osteotomy fixed with tension band wiring. Surgical Technique: An AP (in internal rotation) and a lateral view were obtained preoperatively. The fracture was reduced under image intensifier on fracture table. A pin was passed on anterior surface of the neck for direction A cannulated drill bit was used for fixing the fracture with a 6.5 mm screw before which a superior guide wire was inserted to avoid rotation of the femoral head. Two intramedullary 2.0mm Kirschner wires were inserted through tip of greater trochanter. A 4.5 mm cortical screw was put distal to the planned osteotomy wedge, after which the osteotomy was created and wedge removed (wedge made as in a standard Pauwel osteotomy). The wedge was closed using the tension band wire loop. Care was taken to ensure that the screw threads cross the fracture line, but not the physis. The capsulotomy was performed under image intensification using a scalpel along anterior femoralneck. Wounds were closed in layers and drains were often used. In 3 cases open reduction had to be done because of inability to achieve reduction by closed means [Figure - 1]a.b.c.d.e.f.g.h.

Post operatively, children above 8 years were kept in fixed traction on Thomas splint for 6 weeks after which partial weight bearing was initiated. Full weight bearing depended on the union status and was usually allowed by spica till complete fracture union.

All patients were followed up for an interval of 2-7 years. Clinical results were documented using IOWA hip scores[3],[7]. It evaluates pain, function and hip mobility. Ratliff's classification[8] was used for radiological assessments were done by individuals who were blinded to the trial.


   Results Top


All the 16 femoral neck fractures and their respective osteotomies went on to unite clinically and radiologically at an average of 18 weeks. Three patients developed AVN of which one was Ratliff type 2, involving only a part of femoral head[9],[10]. Significantly in two of these three cases open reduction had been undertaken. The incidence of AVN in this series was only 19% which is considerably low when compared to the other published series[6],[7],[11].One patient developed a mild coxavara deformity and hence a limb length discrepancy of 1 cm. One patient also had a superficial wound infection which healed well with debridement, antibiotics and regular dressings. There were no reports of pin breaking and premature epiphyseal fusion. The mean IOWA hip scores for walking, pain and hip motion were 98, 96 and 98 respectively.

At the final assessment considering the hip scores, 13 patients had an excellent result while 3 patients had a good result. None of the patients had a poor result.


   Discussion Top


Over the world femoral neck fractures in children account for less than 1 % of all pediatric fractures[12],[13],[14] but in our study they accounted for 2.9%. A lot of children in northern part of our country sustain this injury because of fall from trees and poorly constructed roof tops where they sleep on hot summer nights. It explains the higher incidence of this fracture.

By including only Pauwel type 2 and 3 we ensured that the most difficult of femoral neck fractures were chosen for our series. Vertical femoral neck fractures are the ones which bear tremendous shearing forces at the fractures site to give maximum incidences of complications[2],[3] We followed a clear treatment protocol of early, stable internal fixation in form of a 6.5mm noncannulated screw and a primary valgus osteotomy stabilized using tension band wiring.

A noncannulated screw was used because it is economical and probably exerts more compression at the fracture site than a cannulated one. The valgus osteotomy decreases the shearing forces at the fracture site by making it more horizontal thereby increasing chances of uniuon[3],[15].We used tension band wires for stabilizing the osteotomy because we wanted to avoid the use of bulkier implants and the need for a second major operation for plate removal in children. Postoperatively the children were kept on traction even after stable fixation because we could not rely on small children to keep strictly nonweight bearing.

AVN of femoral head is a dreaded complication of this fracture. Overall reported incidence in various series has been from 20% to as high as 40%[1],[13],[14],[15]. It has been proposed that AVN results from interruption of blood supply during initial trauma and the hemarthrosis which creates a capsular tamponade effect[16]. Although the numbers are small yet in our series we managed to keep it down to 19%. We attribute this to initial capsulotomy and early closed reduction and fixation. We had to perform open reduction in 3 cases out of which 2 developed AVN. These factors have also been identified in other studies[6],[11],[17].

Nonunion is another devastating complication of these fractures. The fractures which have been implicated are poor reduction, improper immobilization, and conservative treatment in undeserving fractures, wound infection and implant failure[5]. Various series particularly early ones have reported a very high incidence of nonunion (13% - 36%). Our study does not report a single case of nonunion because all the cases were treated with proper anatomical reduction and stable early fixation. The primary valgus osteotomy decreases the shearing forces at the fractures site and that helped achieve union in all the cases.

Delayed union[3],[6],[13],[18], coxavara and premature epiphyseal closure are other complications which have been high in previous series (15% - 30%). Our series had only one case of a mild coxa vara with 1cm of shortening, probably because of injury to the greater trochanter epiphyses by the tension band wiring construct. During long term follow up (max. 7 years) no problems were encountered at the knee joint.

In conclusion our method of early, stable internal fixation coupled with valgus osteotomy stabilized using tension band wiring is a technically simple yet effective method of treating difficult fracture neck femur. Although a larger series and multicentric trails are needed yet we would safely recommend extension of this technique to stable fractures, to minimize the incidence of complications.

 
   References Top

1.Quick TJ, Eastwood DM. Pediatric fractures and dislocations of the hip and pelvis. Clin Orthop. 2005; 432: 87-96.  Back to cited text no. 1    
2. Colonna PC. Fractures of the neck of the femur in children. Clin Orthop. 1929; 6: 793-797.  Back to cited text no. 2    
3. Canale ST, Beaty JH. Pelvic and hip fractures. In Rockwood CA, Wilkins KE, Beaty JH (Eds) Fractures in Children. Ed 4, Philadelphia; Lippincot Raven. 1996: 1109-1193.  Back to cited text no. 3    
4. Cheng JC, Tang N. Decompression and stable internal fixation of femoral neck fractures in children can affect the outcome. J Paediatr Orthop. 1999; 19: 338-343.  Back to cited text no. 4    
5. Heiser JM, Opphenheim WL. Fracture of the hip in children; a review of 40 cases. Clin Orthop. 1980; 12: 355-358.  Back to cited text no. 5    
6. Canale ST. Fractures of the hip in children and adolescents. Orthop Clin N Am. 1990; 21: 341-352.  Back to cited text no. 6    
7. Davison BL, Weinstein SL. Hip fractures in children. A long-term follow up study. J Paediatr Orthop. 1992; 12: 355-358.  Back to cited text no. 7    
8. Ratlif AHC. Fractures of neck of femur in children. Orthop Clin N Am. 1974; 5: 903-924.  Back to cited text no. 8    
9. Ratliff AHC. Complications after fracture of femoral neck in children and their treatment. J Bone Joint Surg (Br). 1970 ; 52 : 175.  Back to cited text no. 9    
10. Ratiff AHC. Fractures of neck of femur in children. J Bone Joint Surg (Br). 1962; 44: 528-542.  Back to cited text no. 10    
11. Ng CP, Cole WG. Effect of early hip decompression on the frequency of avascular necrosis in childrenwith fracture of neck of femur. Injury 1996; 27: 419-421.  Back to cited text no. 11    
12. Togrul E, Bayram H, Gulsen H. Fractures of femoral neck in children, long term follow up in 62 fractures. Injury. 2005; 36: 123-130.  Back to cited text no. 12    
13. Hughes LO, Beaty JH. Fractures of head and neck of femur in children; current concepts review. J Bone Joint Surg (Am). 1994; 76: 283-292.  Back to cited text no. 13    
14. Mirdad T. Fractures of neck of femur in children. An experience at Aseer Central Hospital, Abha, Saudi Arabia. Injury. 2002; 33: 823-827.  Back to cited text no. 14    
15. Tachdijian MO. Fractures of neck of femur. Pediatric Orthopaedics. second Ed. Philadelphia; WB Saunders Co. 1990: 3231-3247.  Back to cited text no. 15    
16. Trueta J. The normal vascular anatomy of human femoral head during growth. J Bone Joint Surg (Br). 1957; 39: 358-394.  Back to cited text no. 16    
17. Pforringer W, Rosemeyer B. Fractures of hip in children andadolescents. Acta Orthop Scand. 1980; 51: 91-108.  Back to cited text no. 17    
18. Canale ST, Bourland WL. Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg (Am). 1977; 59: 431443.  Back to cited text no. 18    

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Correspondence Address:
K K Pruthi
Department of Orthopaedics, SN Medical College, Agra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.34500

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]



 

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    Abstract
    Introduction
    Material and methods
    Results
    Discussion
    References
    Article Figures
 

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