Management of Pediatric Femoral Neck Fracture

Joseph T. Patterson, MD; Jennifer Tangtiphaiboontana, MD; Nirav K. Pandya, MD


J Am Acad Orthop Surg. 2018;26(12):411-419. 

In This Article

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 musculature may disturb growth and angulation of the femoral neck, producing coxa valga, whereas overgrowth may result in coxa vara.

The proximal femoral physis separates the vascular supplies of the femoral neck and epiphysis from childhood through young adulthood, rendering the developing proximal femur susceptible to vascular injury.[10] Ogden[11] and Trueta[12] characterized this blood supply from birth to adolescence in postmortem dye studies. Branches of the medial and lateral femoral circumflex arteries traverse the physis at birth but attenuate by age 3 to 4 years, leaving no vascular communication 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 posteroinferior branch to the capital epiphysis as well as retinacular vessels that traverse 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% of total supply to the femoral head in early adulthood before declining with age.[11,12]

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.)