Review Article

Management of Pediatric Femoral

Neck Fracture

Abstract
Joseph T. Patterson, MD In the pediatric population, femoral neck fracture is a relatively
Jennifer Tangtiphaiboontana, uncommon injury with a high complication rate, despite
MD appropriate diagnosis and management. The anatomy and blood
Nirav K. Pandya, MD 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.

From the Department of Orthopaedic
Surgery, University of California, San
Francisco, CA.
Dr. Pandya or an immediate family
member serves as a paid consultant
to OrthoPediatrics and serves as a
board member, owner, officer, or
committee member of the Pediatric
Orthopaedic Society of North
America. Neither of the following
authors nor any immediate family
member has received anything of
value from or has stock or stock
options held in a commercial company
or institution related directly or
indirectly to the subject of this article:
Dr. Patterson and
Dr. Tangtiphaiboontana.
J Am Acad Orthop Surg 2018;0:1-9
DOI: 10.5435/JAAOS-D-16-00362
Copyright 2018 by the American
Academy of Orthopaedic Surgeons.
P
of
ediatric femoral neck fractures
are rare injuries that carry the risk
serious complications and
potential long-term disability. Single-
institution series from academic
pediatric tertiary referral centers have
reported pediat- ric femoral neck
fracture incidence rates of 1.2 to 2
cases per year, sug- gesting that
femoral neck fractures annually
account for 0.3% to 0.5% of fractures
in children.1-4 The peak incidence is
at age 10 to 13 years (range, 1 day
to 18 years), with a 1.3 to 1.7:1 ratio
of boys to girls.3,5,6 At long-term
follow-up, adverse out- comes, which
include pain and dis- ability
secondary to osteonecrosis, coxa
valga, proximal femoral physeal
arrest, and nonunion, are reported
in
20% to 50% of patients.1-3,7-9 The
clinician must understand the
current principles of diagnosis,
treatment, postoperative care, and
management of complications to
optimize out-
comes in this population.
Proximal Femoral Anatomy
and Blood Supply
The proximal femur begins to ossify
at
7 weeks of gestation. The medial
portion of the femur gives rise to the
capital femoral epiphysis from one or
multiple ossific nuclei beginning at
age
4 to 6 months and fuses through the
proximal femoral physis at age 14 to
16 years. The lateral nucleus gives
rise
to the traction apophysis of the
greater trochanter. This ossifies
separately and unites with the
proximal femur at age 14 years in
girls and age 16 years in boys.10
Injury to the trochanteric apophysis
or the abductor muscula- ture may
disturb growth and angu- lation of
the femoral neck, producing coxa
valga, whereas overgrowth may
result in coxa vara.
The proximal femoral physis sepa-
rates the vascular supplies of the fem-
oral neck and epiphysis from childhood
through young adulthood, rendering
Month 2018, Vol 0, No 0 1

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Management of Pediatric Femoral Neck Fracture
Figure 1
Illustration of the posterior view of the
vascular supply of a skeletally
immature proximal femur.
(Reproduced from Boardman MJ,
Herman MJ, Buck B, Pizzutillo PD:
Hip fractures in children. J Am Acad
Orthop Surg 2009;17[3]:162-173.)
the developing proximal femur sus-
ceptible to vascular injury.10 Ogden11
and Trueta12 characterized this blood
supply from birth to adolescence in
postmortem dye studies. Branches of
the medial and lateral femoral cir-
cumflex arteries traverse the physis at
birth but attenuate by age 3 to 4
years, leaving no vascular commu-
nication between the metaphysis and
epiphysis until physeal fusion occurs
at age 14 to 17 years. The posterior
superior branch of the lateral
ascending circumflex artery travels
posterosuperior to the physis and
enters the anterolateral capital
femoral epiphysis as the dominant
capital blood supply at age 3 to 4
years. This vessel arises proximally
from the medial femoral circumflex
artery, which also supplies the
femoral epiphysis via a postero-
inferior branch to the capital epiphysis
as well as retinacular vessels that
tra- verse the posterior neck (Figure
1). The contribution of vessels from
the ligamentum teres decreases from
birth to age 4 months and increases
from age 8 years to provide a peak
of 20%
2 Journal of the American Academy of Orthopaedic Surgeons
Figure 2
T2-weighted coronal MRI
demonstrating a stress reaction of
the femoral neck in a 15-year-old
female endurance athlete.
of total supply to the femoral head in
early adulthood before declining with
age.11,12
Presentation
Approximately half of pediatric fem-
oral neck fractures are the result of
high-energy trauma, such as a motor
vehicle accident, sporting event, or
fall from a height and may be
associated with major polytrauma
including injury to the head, chest, or
abdomen, pelvic ring injury,
acetabular fracture, hip dislocation,
and ipsilateral femur fracture.1-
3,5,6,9,13-16
Therefore, care must be
taken to identify other associated
injuries and to collabo- rate with
the general surgery trauma team to
identify nonmusculoskeletal injuries.
Distal neurovascular status and the
presence of open injuries should be
assessed as well.
Twenty-nine percent of femoral
neck fractures are displaced at pre-
sentation.5 Atypical presentation
must be considered as well. In a case
report of a patient who had had
prior hip surgery, bilateral femoral
neck fractures were reported.17 A
low-energy mechanism may suggest
pathologic fractures of the femoral
neck, which can result from uni-
cameral bone cysts, malignancy,
fibrous dysplasia, osteomyelitis, and
congenital metabolic bone diseases
(eg, osteogenesis imperfecta, osteo-
petrosis).6,18 Myelodysplastic patients
are at risk of femoral neck fracture
secondary to disuse osteopeonia.2 In
female adolescent endurance athletes
with functional hypothalamic amen-
orrhea, stress fractures may occur,
despite normal dual-energy x-ray
ab- sorptiometry scores.2,19,20
Presentation of femoral neck frac-
tures is similar in children and adults;
the patients are nonambulatory with
a shortened, externally rotated lower
limb and pain with motion referred to
the groin or knee.13 Pathologic and
stress fractures may be preceded by
insidious onset hip pain.18-20 Non-
accidental trauma should be con-
sidered and investigated; 15% of
pediatric femoral shaft fractures
arise from child abuse,21 but the
prevalence of pediatric femoral neck
fractures associated with abuse has
not been described.
Plain radiographs of the pelvis and
affected hip typically are suffi-
cient to diagnose pediatric femoral
neck fractures. MRI may have a role
in assessment of occult and stress
fractures that are not well charac-
terized by plain radiography (Figure
2). CT can be used to diagnose non-
displaced traumatic fractures, to bet-
ter define proximal femoral anatomy
and/or deformity, or if obtaining
MRI would delay surgical treatment
(Figures 3 and 4).
Classification of Traumatic
Fractures
Fracture classification guides treat-
ment and can be used to counsel
patients on the risk of potential com-
plications before treatment is
initiated. Colonna13 popularized the
Delbet classification of proximal
femoral fractures (Figure 5). Type I
fractures are transphyseal, and types
II, III, and IV are transcervical,
cervicotrochan- teric, and
intertrochanteric fractures,
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Joseph T. Patterson, MD, et al
respectively. This anatomic fracture
Figure 3 Figure 4
classification is prognostic of long-
term outcomes as well as the main
complication of pediatric femoral
neck fractures, osteonecrosis1,2,8
(Figure 6). Osteonecrosis occurs in
16% to 47% of pediatric proximal
femoral fractures1,2,22 and is pre-
sumably secondary to disruption of
the vascular supply to the femoral
head. Ratliff5 classified acute osteo-
necrosis of the femoral head and neck
as radiographic sclerosis and
collapse of the head (type I), focal
sclerosis superior lateral head (type
II), or subcapital neck (type III) with
pres- ervation of the epiphyseal Preoperative coronal CT scan
supply. Many authors report that demonstrating a cystic lesion in the
the long- term outcomes of proximal femur of a 10-year-old boy.
Coronal CT demonstrating a Delbet CT was used for surgical planning.
management of Delbet type I
type III cervicotrochanteric fracture in
fractures are worse compared with a 12-year-old boy. The fracture was
management of other Delbet fracture lished clinical practice guidelines for
not well visualized on initial plain
types.1,2,6,8,15,22 Sub- capital or radiography. management of pediatric diaphyseal
Salter-Harris type I frac- tures with femoral fractures,23 but these guide-
complete dislocation of the lines are not drawn from literature
epiphysis (ie, Delbet type IB) are applicable to femoral neck fractures.
Management of Traumatic
universally thought to progress to
Injury
osteonecrosis regardless of treat- Timing of Fixation
ment (Figure 7). Debate exists on The American Academy of Ortho- Although early reduction of adult hip
whether radiographic evidence of paedic Surgeons (AAOS) has not fractures improves outcomes, the
sclerotic changes associated with published Appropriate Use Criteria effect of early versus late fracture
Ratliff type III fracture reflects os- for the management of pediatric reduction on outcomes in children
teonecrosis rather than routine femoral neck fractures. The AAOS remains unclear. A systematic review
fracture healing.22 has pub-

Figure 5

Illustration of the Delbet classification of hip fractures in children and adolescents. A, Type I, transphyseal fracture, with or
without dislocation of the capital femoral epiphysis. B, Type II, transcervical fracture. C, Type III, cervicotrochanteric fracture.
D, Type IV, intertrochanteric fracture. (Reproduced from Boardman MJ, Herman MJ, Buck B, Pizzutillo PD: Hip fractures in
children. J Am Acad Orthop Surg 2009;17[3]:162-173.)

Month 2018, Vol 0, No 0 3

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Management of Pediatric Femoral Neck Fracture

Figure 6

AP radiograph (A) and three-dimensional CT scan (B) of the proximal femur demonstrating a Delbet type II fracture in a 12-
year-old boy after a fall down stairs. The patient presented to our institution 14 hours after the injury and was taken
immediately to the operating room for fixation. Postoperative AP (C) and lateral (D) radiographs of the proximal femur after
open reduction and internal fixation with cannulated screws through an anterolateral approach. AP (E) and lateral (F)
radiographs demonstrating osteonecrosis 1 year postoperatively.

Figure 7

A, Three-dimensional CT scan of the proximal femur demonstrating a Delbet type IB fracture in a 14-year-old boy who
presented with a dislocated left hip to an outside emergency department. An attempted closed reduction of the hip was
performed without sedation and fluoroscopic guidance, resulting in the injury. Postoperative AP radiographs of the femur
after open reduction and screw fixation demonstrating progressive osteonecrosis immediately after fixation (B), 7 months
after fixation (C), and at the time of implant removal at 1 year after fixation (D).

4 Journal of the American Academy of Orthopaedic Surgeons

Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Joseph T. Patterson, MD, et al
of 30 studies comprising 935 patients
reported that the rate of osteonecrosis
was 4.2 times higher in patients who
had delayed treatment compared
with those who underwent treatment
within 24 hours of injury.7 When
fixation was delayed at least 24
hours after injury, a high incidence
of complications occurred, with
64% of patients showing premature
physeal arrest and 55% with osteo-
necrosis.24 However, recent studies
have demonstrated that shorter time
to reduction (#12 hours) did not
reduce the rate of osteonecrosis in
children with femoral neck fractures
and may in fact be a positive pre-
dictor of osteonecrosis.16,25 Although
limited and contradicting evidence
exists in the literature with regard to
the timing of fixation, Spence et al16
and Gopinathan et al17 believe that
anatomic reduction of a hip fracture
should occur as soon as possible.
Closed Versus Open
Reduction
Selection of closed versus open
reduction depends on the amount of
fracture displacement present and the
surgeon’s ability to achieve anatomic
or near-anatomic reduction in a
closed fashion. Patients are placed
supine on either a radiolucent oper-
ating table or fracture table and
reduction is assessed with intra-
operative fluoroscopy. When closed
reduction is performed with the
patient on a fracture table, the hip is
hyperextended with abduction and
internal rotation, and slight knee
flexion is maintained. Gentle longi-
tudinal traction is applied and the
hip is placed in a spica cast or per-
cutaneous fixation is placed. We
advocate for the use of open reduc-
tion when an anatomic reduction
cannot be achieved.
Open reduction and internal fixa-
tion (ORIF) typically is used for
severely displaced fractures or in
patients in whom anatomic reduction
Month 2018, Vol 0, No 0
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
cannot be achieved with closed
reduction. In addition, when a frac-
ture has occurred through a sus-
pected pathologic lesion, open
reduction may be necessary to con-
firm the lesion diagnosis and manage
associated pathology (Figure 4).
Evidence regarding the benefit of
open reduction in reducing compli-
cations such as osteonecrosis is
inconclusive. Several studies have
shown that completely displaced
femoral neck fractures treated with
ORIF had a better reduction, higher
rate of union, and fewer complica-
tions (eg, osteonecrosis) when com-
pared with displaced femoral neck
fractures treated with closed reduc-
tion with fixation.26,27 However,
other studies have shown that open
reduction has been associated with
higher rates of osteonecrosis.7,28
Authors of these studies advise cau-
tion when interpreting these results
because fractures that require open
reduction may be substantially dis-
placed and therefore may inherently
have a high risk for osteonecrosis as
a result of the injury itself.
Fractures that require ORIF may
be accessed through an anterior
(ie, Smith-Peterson), anterolateral
(ie, Watson-Jones), or lateral (ie,
Hardinge) approach to the hip. The
anterior approach affords excellent
visualization of the hip joint but a
separate incision may be required
to place fixation. Anatomic frac-
ture reduction with stable fixation
is the goal of treatment.
Aspiration and Capsulotomy
The role of capsular decompression
after reduction and fixation of hip
fractures has been limited to case
series and systematic reviews. One
case series reported a lower incidence
of osteonecrosis in children who had
hip capsular decompression than in
those treated without capsular decom-
pression.27 Methods used to achieve
capsular decompression include aspi-
ration of a capsular hematoma with
a large-bore needle or anterior hip
approach and open capsulotomy
through a small anterior incision.
These procedures are relatively
straightforward to perform and
may theoretically decrease the risk of
osteonecrosis; however, the available
data fail to show a statistically sig-
nificant difference in reducing the
occurrence of osteonecrosis.7,16,29
Fixation Based on Fracture
Type
The achievement of fracture stability
with fixation must be weighed
against the risk of potential physeal
injury and premature closure. Trans-
physeal screws are ideally placed no
less than 5 mm from the subchondral
bone of the femoral head. Care must
to taken to avoid posterior perfora-
tion or screw placement in the an-
terolateral quadrant of the
epiphysis to reduce the risk of
iatrogenic injury to the blood
vessels. Physeal-sparing fixation
methods include trans- physeal
fixation with smooth wires or
placement of screws that do not
cross the physis. Although we prefer
to avoid placing screws across the
physis in patients aged ,10 years,
both the Delbet fracture type and the
skeletal maturity or age of the patient
must be considered when choosing
the appropriate method of fracture
fixation. Stable fracture fixation
should not be compromised to spare
the physis.
Delbet Type I
Closed reduction may be used to
manage minimally displaced type I
fractures, with a spica cast applied
postoperatively for immobilization in
children aged ,2 years. Fractures in
patients aged 2 to 9 years should be
stabilized with two smooth pins and
immobilized with a spica cast post-
operatively. Transphyseal fixation is
recommended for fracture manage-
ment in patients aged $10 years.
5
Management of Pediatric Femoral Neck Fracture
ORIF is required to manage fractures
with a dislocated epiphysis using a
direct anterior, posterior, or surgical
dislocation approach depending on
the direction of the dislocation,
location of the epiphysis, and sur-
geon experience (Figure 7).
Delbet Types II and III
Type II and type III fractures are the
most common type of pediatric fem-
oral neck fracture and are often dis-
placed. Nondisplaced fractures in
young children (aged ,6 years) may
be treated with closed reduction and
spica cast immobilization. Supple-
spica cast when ,10 of angulation repetitive running and jumping.
is obtained and maintained in the Stress fractures are thought to result
cast. Supplemental fixation can be from repetitive, unaccustomed stress
used in patients aged $2 years to that is below the threshold of energy
prevent displacement within the cast. required to cause a complete acute
Patients aged .6 years should fracture but is sufficient to interfere
undergo sur- gical stabilization with with the body’s normal bone re-
a pediatric sliding hip screw, blade modeling mechanism. Several
plate, or proximal femoral locking authors have proposed classification
plate. A physeal sparing screw should systems based on the location of the
be considered in younger patients stress fracture and/or radiographic
aged find-
,10 years. A transphyseal hip screw ings.31,32 Pediatric femoral neck stress
should be used in adolescent fractures commonly occur on the
patients inferior, compression side of the
for increased stability. An additional femoral neck; however, tension-
guidewire or screw should be placed sided stress fractures have also
before placement of the hip screw to 33

mental fixation can be used in
patients aged $2 years to prevent
displacement within the cast. Because
of the risk of nonunion and femoral
head-neck offset from malunion,
acceptable reduction in type II frac-
tures consists of ,5 of angulation
and ,2 mm of cortical translation.
Acceptable reduction in type III
fractures consists of ,10 of angula-
tion, with varus malalignment being
most common. Displaced fractures
that cannot be managed with closed
reduction should be managed with
ORIF using smooth Kirschner wires
in patients aged ,4 years,
physeal- sparing cannulated screws
in those aged 4 to 9 years, or
transphyseal cannulated screws in
those aged $10
years. Transphyseal screw fixation
is
recommended for fractures with a
small metaphyseal fracture fragment
resulting from insufficient fixation
stability. Patients with an unstable
fracture pattern may require alterna-
tive methods of fixation (ie, proximal
femoral plates) because of the high
rate of failure with screw fixation
alone and the risk of posttraumatic
coxa vara.30
Delbet Type IV
Nondisplaced or minimally displaced
type IV fractures in patients aged ,6
years may be managed with closed
reduction and immobilization in a
prevent fracture displacement or been described.
rotation. Hip screws also should be
predrilled and tapped because of the
hard, dense bone in otherwise healthy
children.
Postoperative Management
Patients are followed closely post-
operatively, with radiographs ob-
tained to assess for interval fracture
displacement or implant failure. The
need for additional spica cast immo-
bilization after surgical stabilization
depends on the fracture type, patient
age, quality of the fixation, and
compliance with postoperative
weight-bearing and activity restric-
tions. Patients with stable fracture
patterns who are treated with trans-
physeal fixation do not require spica
casting and may ambulate with
crutches and toe-touch weight bear-
ing. Fracture immobilization or
weight-bearing precautions continue
for 6 to 8 weeks or until fracture
union is achieved. Adolescents may
benefit from formal physical therapy
after fracture healing to assist with
gait training and strengthening.
Management of Atraumatic
and Insufficiency Factors
Femoral neck stress fractures are
becoming more common because of
increased participation in sports and
In the absence of a
traumatic event or an increase in
repetitive physical activity level, a
pediatric femoral neck stress frac-
ture warrants a thorough endocrine
and metabolic workup, including a
complete blood count, electro-
lyte panel, liver function tests, thy-
roid hormone, 25-vitamin D level,
erythrocyte sedimentation rate, and
C-reactive protein level.
Although management of femoral
stress fractures in adults and athletes
has been well described, management
of pediatric femoral neck stress frac-
tures has been limited to case reports
and series. Initial management of
these stress fractures includes a
period of activity modification and
weight-bearing restrictions. Boyle
34
et al reported on six otherwise
healthy patients (average age, 7.7
years) with idiopathic, compression-
type femoral neck stress fractures.
Four patients healed after 6 to 8
weeks of non-weight bearing re-
striction followed by 4 to 6 weeks of
partial weight bearing. To achieve
complete healing, two patients
required additional immobilization
in a hip spica cast because of poor
compliance with weight-bearing re-
strictions. Although nonsurgical
treatment can lead to successful
healing, patients with tension-sided
stress fractures or those who do not
heal with prolonged nonsurgical
6 Journal of the American Academy of Orthopaedic Surgeons

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Joseph T. Patterson, MD, et al
treatment may require surgical fix-
ation with cannulated screws.33
Identification of the risk factors for
tension-sided stress fractures of the
femoral neck is crucial for selection
of appropriate intervention.
Complications
The reported overall complication
rate after management of femoral
neck fracture is approximately
33%.28 Osteonecrosis is the most
common complication; other com-
plications include premature physeal
closure, coxa vara deformity, the
need for revision surgery, nonunion,
surgical site infection, septic arthri-
tis, posttraumatic slipped capital
femoral epiphysis (SCFE), and
overgrowth of the femoral neck.7,28
Osteonecrosis
Osteonecrosis is the most common
and debilitating complication of
traumatic pediatric femoral neck
fractures, occurring in 20% to 29%
of patients after surgical reduction
and fixation.7,16,25,26 Development
of osteonecrosis is associated with
fracture displacement, fracture
location (Delbet types I and II), and
closed management via casting or
closed reduction with internal fixa-
tion.16,26 Spence et al16 reported that
osteonecrosis was nine times as likely
to develop in the setting of displaced
fractures compared with non-
displaced fractures. In the setting of
Delbet type I and II fractures,
development of osteonecrosis was 14
times and 4 times more likely,
respectively, compared with type III
fractures. The reported rates of os-
teonecrosis according to the Delbet
classification are 38% to 50% for
type I, 28% for type II, 8% to 18%
for type III, and 5% to 10% for type
IV.25,35 Age .10 years also has been
shown to be a factor in increased risk
of osteonecrosis.25,28,35 Although sev-
eral studies linked osteonecrosis with
Month 2018, Vol 0, No 0
capsular decompression, open fixa-
tion method, fracture alignment
after reduction and fixation, and
injury mechanism,7,19,27 recent
studies and meta-analyses have not
supported these findings.7,9,16,26 The
relation- ship between time to open
surgical fixation and the
development of os- teonecrosis
remains unclear, with higher rates of
osteonecrosis reported in the setting
of early and late fixa-
tion.9,15,16,24,29 Osteonecrosis has
led to coxa vara deformity in 6% to
33% of cases managed
nonsurgically.1,2,6
In a study of six patients with os-
teonecrosis associated with femoral
neck fractures, core biopsies of the
fracture site at the time of device
removal demonstrated empty trabec-
ular lacunae and bone marrow
necrosis in patients with minimally
displaced fracture with incomplete
repair .1 year after injury.36
Osteonecrosis is most likely the
result of vascular injury that occurs at
the time of fracture. Proposed mech-
anisms include kinking or direct lac-
eration of the blood vessels or
ischemia from tamponade of the
vessels as a result of an increase in-
tracapsular pressure. Inconclusive
evidence exists in the current litera-
ture to support urgent reduction and
fixation with capsular decompression
to reduce the risk of osteonecrosis.
The median time to development of
osteonecrosis is 7.8 months from
injury (range, 2.7 to 31.4 months),
but osteonecrosis can take up to 2
years to develop.16 Therefore,
patients should be followed closely,
with annual radiographs obtained
until the patient reaches skeletal
maturity.7,16 If early signs of
osteonecrosis are present on plain
radiographs, MRI with metal sub-
traction sequences can be obtained.
Ratliff 5 characterized osteonecrosis
of the hip as involvement of the
entire femoral head (type I), con-
finement to segments of the head
(type II), or involvement of the
femoral neck (type III). Prognosis
and management options vary de-
pending on the type of osteonec-
rosis, the degree of deformity and
collapse, and the age at which the
condition becomes symptomatic. If
detected early, osteonecrosis can be
managed with anti-inflammatories,
physical therapy, and limitation of
impact activities.
Septic Arthritis
Postoperative infection is a rare com-
plication of hip fractures in children,
occurring in up to 5.2% of
patients.1,2,7
Infection has been reported after
both
open and closed reduction with per-
cutaneous fixation.37 Early diagnosis
and management of infection with
antibiotics and wound débridement
may improve outcomes and prevent
sequelae such as osteomyelitis, osteo-
necrosis, premature physeal closure,
and chondrolysis.
Nonunion
Nonunion, which is defined as failure
of fracture healing after 4 to 6 months
of treatment, has been reported in up
to 10% of pediatric patients with
femoral neck fractures and is most
common in patients with type II
fractures and least common in those
with type IV fractures.7 Fractures
that were not anatomically reduced
or in which fixation was either
inadequate or failed may also result
in nonunion. Management of non-
unions involves a valgus osteotomy
to convert shear forces to compres-
sive forces and to promote fracture
healing.38 Fibular osteosynthesis also
has been described as a management
option for nonunion; however, this
method does not address any coxa
vara deformity that commonly
occurs with fracture nonunion.39
Coxa Vara
Early studies of pediatric femoral
neck fractures noted that malunion
leads to limp, femoroacetabular
7
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Management of Pediatric Femoral Neck Fracture
impingement, early arthritis, and
progressive disability.13 Coxa vara
deformity, which is defined as a
femoral neck-shaft angle of ,120 ,
is a common complication of femo-
ral neck fractures in children, with a
reported incidence of up to 18%.7
Although mild coxa vara deformity
in young children may remodel with
growth, more severe deformity may
require surgical correction. Magu
et al38 reported that a valgus Pauwels
intertrochanteric osteotomy can
produce good results (eg, high rates
of union and deformity correction)
and may have a role in restoring the
viability of the femoral head in the
setting of osteonecrosis.
Premature Physeal Closure
Reports of premature physeal closure
after hip fracture vary widely, with an
incidence ranging from 20% to
62%.1,2,5-7 Mechanisms of injury
include direct trauma to the physis or
injury to the blood supply, either
from the fracture itself or surgical
management. Partial premature
physeal arrest may result in coxa
vara and coxa valga deformities of
the proximal femur. The assessment
of premature physeal closure before
the development of deformity or
limb-length discrepancy may be dif-
ficult; however, MRI may be helpful
to detect physeal injuries and bar
formation, providing better prog-
nostic information.40 The proximal
femoral physis contributes approxi-
mately 15% of the overall length of
the femur. Complete physeal closure
in very young children (aged ,10
years and/or with .2 years of
growth remaining) may result in a
substantial limb-length discrepancy
(.2 cm). Older children and ado-
lescents with premature physeal
closure may go on to have a clinically
significant limb-length discrepancy.
Patients with a limb-length discrep-
ancy of ,2 cm may be treated non-
surgically with a shoe lift; however,
8 Journal of the American Academy of Orthopaedic Surgeons
Copyright the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
those with a larger limb-length dis-
crepancy may require epiphysiodesis
of the distal femur and/or proximal
tibia of the contralateral limb.
Posttraumatic SCFE and
Overgrowth of the Femoral
Neck
Delayed SCFE is another complica-
tion of femoral neck fracture. In a
small series of Delbet type II and III
femoral neck fractures treated surgi-
cally, Li et al41 observed this com-
plication at an average of 9 months
after fracture management (range, 5
weeks to 15 months). The delayed
SCFE may have been a result of
implant irritation, premature initia-
tion of weight bearing, coxa vara
deformity, osteonecrosis, delayed
union, or nonunion.
Overgrowth of the femoral shaft
after fracture has been well described
in the pediatric population, but little
attention has been paid to over-
growth of the femoral neck after
fracture. Kuo et al42 reported on a
series of 30 femoral neck fractures in
30 patients, in which 12 patients
demonstrated an average femoral
overgrowth of 6.2 mm. Patients with
overgrowth were younger (mean
age, 5.5 years versus 9.9 years), had
a lower rate of osteonecrosis, and
had better functional outcomes.
Summary
In the pediatric population, femoral
neck fractures are a rare injury with
potentially disabling long-term
sequelae. Although debate exists on
the management of these injuries in
regard to surgical timing, surgical
approach, and fixation, the goal
of treatment remains unchanged:
achieve fracture union and ana-
tomic reduction while avoiding
osteonecrosis. The Delbet classifica-
tion provides insight on prognosis
and guides treatment. Coxa vara,
nonunion, and physeal arrest may be
encountered by the treating clinician
after fracture fixation. Diagnosis of
femoral stress fractures in this pop-
ulation is also critical, and risk factors
for the development of these fractures
must be fully explored.
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Month 2018, Vol 0, No 0 9

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