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

Classification of Traumatic Fractures

Fracture classification guides treatment and can be used to counsel patients on the risk of potential complications before treatment is initiated. Colonna[13] popularized the Delbet classification of proximal femoral fractures (Figure 5). Type I fractures are transphyseal, and types II, III, and IV are transcervical, cervicotrochanteric, and intertrochanteric fractures, respectively. This anatomic fracture classification is prognostic of long-term outcomes as well as the main complication of pediatric femoral neck fractures, osteonecrosis[1,2,8] (Figure 6). Osteonecrosis occurs in 16% to 47% of pediatric proximal femoral fractures[1,2,22] and is presumably secondary to disruption of the vascular supply to the femoral head. Ratliff[5] classified acute osteonecrosis 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 preservation of the epiphyseal supply. Many authors report that the long-term outcomes of management of Delbet type I fractures are worse compared with management of other Delbet fracture types.[1,2,6,8,15,22] Subcapital or Salter-Harris type I fractures with complete dislocation of the epiphysis (ie, Delbet type IB) are universally thought to progress to osteonecrosis regardless of treatment (Figure 7). Debate exists on whether radiographic evidence of sclerotic changes associated with Ratliff type III fracture reflects osteonecrosis rather than routine fracture healing.[22]

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.)

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).