Management of Pediatric Femoral Neck Fracture

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

Disclosures

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

In This Article

Presentation

Approximately half of pediatric femoral 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 collaborate 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 presentation.[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 unicameral bone cysts, malignancy, fibrous dysplasia, osteomyelitis, and congenital metabolic bone diseases (eg, osteogenesis imperfecta, osteopetrosis).[6,18] Myelodysplastic patients are at risk of femoral neck fracture secondary to disuse osteopeonia.[2] In female adolescent endurance athletes with functional hypothalamic amenorrhea, stress fractures may occur, despite normal dual-energy x-ray absorptiometry scores.[2,19,20]

Presentation of femoral neck fractures 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] Nonaccidental trauma should be considered 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 sufficient to diagnose pediatric femoral neck fractures. MRI may have a role in assessment of occult and stress fractures that are not well characterized by plain radiography (Figure 2). CT can be used to diagnose nondisplaced traumatic fractures, to better define proximal femoral anatomy and/or deformity, or if obtaining MRI would delay surgical treatment (Figures 3 and 4).

Figure 2.

T2-weighted coronal MRI demonstrating a stress reaction of the femoral neck in a 15-year-old female endurance athlete.

Figure 3.

Coronal CT demonstrating a Delbet type III cervicotrochanteric fracture in a 12-year-old boy. The fracture was not well visualized on initial plain radiography.

Figure 4.

Preoperative coronal CT scan demonstrating a cystic lesion in the proximal femur of a 10-year-old boy. CT was used for surgical planning.

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