The Open Orthopaedics Journal




ISSN: 1874-3250 ― Volume 13, 2019

Transphyseal Femoral Neck Fracture in a Twenty-Month Old Male Child



Matthew J. Brown*, Michael R. Ferrick
Department of Orthopaedics, State University of New York at Buffalo, 462 Grider St., Buffalo, NY 14215, USA

Abstract

Transphyseal femoral neck fractures are an extremely rare event, mainly occurring in children subjected to an significant traumatic force. The diagnosis is usually suggested by clinical examination with radiographic confirmation. Management varies; however, no consensus exists as to proper treatment. Intervention is primarily focused on the prevention of avascular necrosis (AVN) of the femoral epiphysis.

We present the case of a 20-month-old male with a delayed diagnosis of transphyseal femoral neck fracture. X-ray (XR) and computed tomography (CT) scan images were used for diagnosis, to track healing, and monitor the possible emergence of avascular necrosis. Final imaging demonstrated full healing without AVN at two years.

This study demonstrates the successful treatment of a rare pediatric fracture type with possible life-changing complications. Reduction, surgical fixation with K-wires, and spica casting are demonstrated as being acceptable treatment in the very young transphyseal fracture patient.

Keywords: Transphyseal femoral neck fracture, avascular necrosis.


Article Information


Identifiers and Pagination:

Year: 2016
Volume: 10
First Page: 56
Last Page: 61
Publisher Id: TOORTHJ-10-56
DOI: 10.2174/1874325001610010056

Article History:

Received Date: 03/03/2015
Revision Received Date: 01/05/2015
Acceptance Date: 02/06/2015
Electronic publication date: 31/03/2016
Collection year: 2016

Article Metrics:

CrossRef Citations:
0

Total Statistics:

Full-Text HTML Views: 1622
Abstract HTML Views: 818
PDF Downloads: 304
ePub Downloads: 191
Total Views/Downloads: 2935

Unique Statistics:

Full-Text HTML Views: 725
Abstract HTML Views: 449
PDF Downloads: 186
ePub Downloads: 129
Total Views/Downloads: 1489
Geographical View

© Brown and Ferrick; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution-Non-Commercial 4.0 International Public License (CC BY-NC 4.0) (https://creativecommons.org/licenses/by-nc/4.0/legalcode), which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to this authors at the Department of Orthopaedics, State University of New York at Buffalo, 462 Grider St., Buffalo, NY 14215, USA; Tel: 314-541-4144; Fax: 716-898-3323; E-mail: mjb9rc@mail.missouri.edu




INTRODUCTION

The incidence of avascular necrosis in children suffering from transphyseal femoral neck fractures has been reported to be up to 90%. The incidence of femoral neck fractures is much lower in children than in adults and usually due to high-energy trauma [1Hughes LO, Beaty JH. Current concepts review: fractures of the head and neck of the femur in children. J Bone Joint Surg Am 1994; 76(2): 283-92.
[PMID: 8113267]
]. Of these fractures, Delbet type I, or transphyseal femoral neck fractures, are the least common, occurring in roughly 8% of femoral neck fractures in a metanalysis [1Hughes LO, Beaty JH. Current concepts review: fractures of the head and neck of the femur in children. J Bone Joint Surg Am 1994; 76(2): 283-92.
[PMID: 8113267]
]. The incidence is rare enough that the relevant literature citations involve no more than eleven patients in any single study [2Ogden JA. Hip development and vascularity: Relationship to chondro-osseous trauma in the growing child. In: St. Louis CV, Ed. the HIP: Proceedings of the ninth open scientific meeting of the hip society. Mosby 1981; pp. 139-87.
[PMID: 863935]
].

The most common complication when dealing with Delbet Type I fractures is the high incidence of avascular necrosis of the femoral epiphysis. This occurs more often in the fractures associated with dislocation, however any patient is at a higher risk simply due to the transphyseal nature of the fracture [1Hughes LO, Beaty JH. Current concepts review: fractures of the head and neck of the femur in children. J Bone Joint Surg Am 1994; 76(2): 283-92.
[PMID: 8113267]
, 3Canale ST, Bourland WL. Fracture of the neck and intertrochan- teric region of the femur in children. J Bone Joint Surg Am 1977; 59(4): 431-43., 4Canale ST, Beaty JH. Pelvic and hip fractures. In: Rockwood CA, Jr, Wilkins KE, Beaty JH, Eds. Fractures in children. 4th ed. Philadelphia: Lippincott-Raven 1996; pp. 1109-3.Moon ES, Mehlman CT. Risk factors for avascular necrosis after femoral neck fractures in children: 25 Cincinnati cases and meta-analysis of 360 cases. J Orthop Trauma 2006; 20(5): 323-9.
[http://dx.doi.org/10.1097/00005131-200605000-00005] [PMID: 16766935]
]. The available literature is scant, so much so that a PUBMED search for “transphyseal femoral neck fracture” reveals exactly twenty papers, of which almost all of the relevant papers are case studies.

CASE REPORT

The patient is a 20-month-old male child who presented to the emergency room after falling from a second-story window. The child stood up after the fall and was ambulating at the scene with a limp of his right lower extremity. A multidisciplinary group evaluated the patient and he was admitted overnight after initial evaluation, which revealed no fractures or dislocations in his cervical spine or bilateral lower extremities (Fig. 1). Orthopaedically, he was diagnosed with a right leg contusion and instructed to follow up in one week.

Fig. (1)

Initial XR and CT of twenty-month-old male child demonstrating no fracture or dislocation of right hip. Arrow delineates the physis.



The patient returned to the Emergency Room seven days later with an antalgic gait, toe walking, and protected weight bearing on the right lower extremity. Mother stated he had been refusing to bear weight fully and had regressed to cruising on the furniture. Orthopaedics was consulted and the patient’s pelvic radiographs demonstrated a displaced transphyseal fracture (Fig. 2).

Fig. (2)

Displaced trans-physeal fracture in twenty-month-old male child.



In the operating room, the fracture was reduced with gentle internal rotation and flexion at the hip, and two 0.062mm K-wires were placed from the lateral proximal femoral cortex up the femoral neck, across the physis, and into the epiphysis. Alignment was verified fluoroscopically (Fig. 3). In the operating room a one-and-a-half leg spica cast was placed. Patient was monitored overnight and discharged the next day.

Fig. (3)

Operative reduction and pinning of fracture in twenty-month-old male child.



The patient was maintained comfortably in the spica cast for 6 total weeks, with two clinical visits to ensure cast condition and comfort. At six weeks, the patient’s pins were removed and his parents were instructed to keep him non- weight-bearing as long as possible. By the next visit at ten weeks after surgery, the patient was fully weight bearing and had resumed all activities. He continued to be followed for another two years, with full radiographic healing, no osteonecrosis, a normal-appearing physis, and normal function noted (Fig. 4).

Fig. (4)

Two year follow-up after pin removal and return to weight bearing in four year old male child.



DISCUSSION

Transphyseal fractures of the femoral neck in children are rare, occurring least often in the Delbet classification [1Hughes LO, Beaty JH. Current concepts review: fractures of the head and neck of the femur in children. J Bone Joint Surg Am 1994; 76(2): 283-92.
[PMID: 8113267]
]. This rare fracture pattern tends to occur most often in young children after high-energy trauma [2Ogden JA. Hip development and vascularity: Relationship to chondro-osseous trauma in the growing child. In: St. Louis CV, Ed. the HIP: Proceedings of the ninth open scientific meeting of the hip society. Mosby 1981; pp. 139-87.
[PMID: 863935]
]. Although rare, they have the highest risk of avascular necrosis of the Delbet fracture types. A meta-analysis demonstrated that a type I fracture is 14 times more likely than type IV fractures to develop AVN [5Heiser JM, Oppenheim WL. Fractures of the hip in children: a review of forty cases. Clin Orthop Relat Res 1980; (149): 177-84.
[PMID: 7408300]
]. They can also occur in conjunction with a hip dislocation, which usually portends a much worse prognosis [3Canale ST, Bourland WL. Fracture of the neck and intertrochan- teric region of the femur in children. J Bone Joint Surg Am 1977; 59(4): 431-43.]. In general, Delbet Type I fractures without dislocations in young children have a better prognosis than those with dislocations [4Canale ST, Beaty JH. Pelvic and hip fractures. In: Rockwood CA, Jr, Wilkins KE, Beaty JH, Eds. Fractures in children. 4th ed. Philadelphia: Lippincott-Raven 1996; pp. 1109-3.Moon ES, Mehlman CT. Risk factors for avascular necrosis after femoral neck fractures in children: 25 Cincinnati cases and meta-analysis of 360 cases. J Orthop Trauma 2006; 20(5): 323-9.
[http://dx.doi.org/10.1097/00005131-200605000-00005] [PMID: 16766935]
].

The most common complication seen in this fracture population is avascular necrosis of the femoral head. In the early literature, the risk of AVN in a Delbet Type I fracture was as high as 100% [3Canale ST, Bourland WL. Fracture of the neck and intertrochan- teric region of the femur in children. J Bone Joint Surg Am 1977; 59(4): 431-43.]. In current literature, the risk is in the range of 38% [5Heiser JM, Oppenheim WL. Fractures of the hip in children: a review of forty cases. Clin Orthop Relat Res 1980; (149): 177-84.
[PMID: 7408300]
]. Damage to the retinacular vessels may compromise blood flow to the femoral head resulting in the distinct patterns of AVN seen in children [6Onstenk R, van Eeckhoudt SJ, Bos CF, Reinders ME, Aronson DC. Avascular necrosis of the head in paediatric hip fractures, an inevitable complication. Eur J Orthop Surg Traumatol 2002; 12(2): 75-80.
[http://dx.doi.org/10.1007/s00590-002-0019-4] [PMID: 24570157]
]. Ratliff defined AVN of the pediatric femoral head as: type I (diffuse necrosis of the femoral head and neck distal to the fracture), type II (necrosis confined to the epiphysis), and type III (necrosis of the femoral neck with sparing of the epiphysis) [7Forlin E, Guille JT, Kumar SJ, Rhee KJ. Transepiphyseal fractures of the neck of the femur in very young children. J Pediatr Orthop 1992; 12(2): 164-8.
[http://dx.doi.org/10.1097/01241398-199203000-00004] [PMID: 1552017]
]. The Ratliff types seen in transphyseal fractures are Ratliff I and II, secondary to the retinacular vessel damage [9Miller WE. Fractures of the hip in children from birth to adolescence. Clin Orthop Relat Res 1973; (92): 155-88.
[http://dx.doi.org/10.1097/00003086-197305000-00014] [PMID: 4710831]
].

The decreased risk of AVN seen in the more recent literature may be attributable to the differences in fracture care. In the past, the standard treatment of a femoral neck fracture in a child was closed reduction with spica casting, whereas, current treatment consists of closed or open reduction and fixation using percutaneous pins or screws [8Cannon SR, Pool CJ. Traumatic separation of the proximal femoral epiphysis and fracture of the mid-shaft of the ipsilateral femur in a child. A case report and review of the literature. Injury 1983; 15(3): 156-8.
[http://dx.doi.org/10.1016/0020-1383(83)90003-7] [PMID: 6642623]
]. Gentle closed reduction and fixation with smooth pins in younger patients is indicated for type-I fractures without dislocation [1Hughes LO, Beaty JH. Current concepts review: fractures of the head and neck of the femur in children. J Bone Joint Surg Am 1994; 76(2): 283-92.
[PMID: 8113267]
]. It has been suggested that, in children younger than two years old, closed reduction and application of a spica cast without internal fixation may be adequate with a fluoroscopically demonstrated stable reduction [9Miller WE. Fractures of the hip in children from birth to adolescence. Clin Orthop Relat Res 1973; (92): 155-88.
[http://dx.doi.org/10.1097/00003086-197305000-00014] [PMID: 4710831]
, 10Bagatur AE, Zorer G. Complications associated with surgically treated hip fractures in children. J Pediatr Orthop B 2002; 11(3): 219-28.
[PMID: 12089498]
].

Younger children with the fracture type seen in our patient typically do better than those patients of an older age. A meta-analysis of femoral neck fractures calculated that older children were 14 times more likely to develop AVN for every year of increasing age [5Heiser JM, Oppenheim WL. Fractures of the hip in children: a review of forty cases. Clin Orthop Relat Res 1980; (149): 177-84.
[PMID: 7408300]
]. Forlin and Miller demonstrated improved outcomes in type-I fractures in children younger than two and a half years old [8Cannon SR, Pool CJ. Traumatic separation of the proximal femoral epiphysis and fracture of the mid-shaft of the ipsilateral femur in a child. A case report and review of the literature. Injury 1983; 15(3): 156-8.
[http://dx.doi.org/10.1016/0020-1383(83)90003-7] [PMID: 6642623]
, 12Varshney MK, Kumar A, Khan SA, Rastogi S. Functional and radiological outcome after delayed fixation of femoral neck fractures in pediatric patients. J Orthop Traumatol 2009; 10(4): 211-6.
[http://dx.doi.org/10.1007/s10195-009-0072-4] [PMID: 19936885]
]. It has been suggested that these results may be due to the increased ability of very young children to revascularize and remodel the femoral head [11Forlin E, Guille JT, Kumar SJ, Rhee KJ. Complications associated with fracture of the neck of the femur in children. J Pediatr Orthop 1992; 12(4): 503-9.
[http://dx.doi.org/10.1097/01241398-199207000-00017] [PMID: 1613096]
].

The excellent outcome of our patient occurred despite a delay in accurate diagnosis for seven days. This experience is consistent with previous reports in the literature, most recently with a study evaluating delayed (>24 hours) treatment for femoral neck fractures demonstrating a 14.3% AVN rate. The AVN rate was significantly affected by the amount of delay (>10 days) and the use of open reduction [13Bali K, Sudesh P, Patel S, Kumar V, Saini U, Dhillon MS. Pediatric femoral neck fractures: our 10 years of experience. Clin Orthop Surg 2011; 3(4): 302-8.
[http://dx.doi.org/10.4055/cios.2011.3.4.302] [PMID: 22162793]
]. These results are similar to another study done in India, which demonstrated a 19.4% AVN rate in patients treated in less than 24 hours after injury [14].

Despite the severity of his fracture and the delay in treatment, our patient did well, with his young age benefiting his outcome. The use of a closed reduction in this case possibly worked to our advantage, with initial healing minimally disturbed by the closed reduction and K-wire fixation. The lack of AVN greater than two years after his fracture portends a normal future, although the risk for leg length discrepancy may remain. The care provided here in addition to the patient’s young age may have allowed for the excellent outcome, however, he might have simply been in the 60% or more of patients who do well.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflict of interest.

ACKNOWLEDGEMENTS

The authors have not received grant support or research funding and have no proprietary interests in the materials described in the article.

REFERENCES

[1] Hughes LO, Beaty JH. Current concepts review: fractures of the head and neck of the femur in children. J Bone Joint Surg Am 1994; 76(2): 283-92.
[PMID: 8113267]
[2] Ogden JA. Hip development and vascularity: Relationship to chondro-osseous trauma in the growing child. In: St. Louis CV, Ed. the HIP: Proceedings of the ninth open scientific meeting of the hip society. Mosby 1981; pp. 139-87.
[PMID: 863935]
[3] Canale ST, Bourland WL. Fracture of the neck and intertrochan- teric region of the femur in children. J Bone Joint Surg Am 1977; 59(4): 431-43.
[4] Canale ST, Beaty JH. Pelvic and hip fractures. In: Rockwood CA, Jr, Wilkins KE, Beaty JH, Eds. Fractures in children. 4th ed. Philadelphia: Lippincott-Raven 1996; pp. 1109-3.
[5] Moon ES, Mehlman CT. Risk factors for avascular necrosis after femoral neck fractures in children: 25 Cincinnati cases and meta-analysis of 360 cases. J Orthop Trauma 2006; 20(5): 323-9.
[http://dx.doi.org/10.1097/00005131-200605000-00005] [PMID: 16766935]
[6] Heiser JM, Oppenheim WL. Fractures of the hip in children: a review of forty cases. Clin Orthop Relat Res 1980; (149): 177-84.
[PMID: 7408300]
[7] Onstenk R, van Eeckhoudt SJ, Bos CF, Reinders ME, Aronson DC. Avascular necrosis of the head in paediatric hip fractures, an inevitable complication. Eur J Orthop Surg Traumatol 2002; 12(2): 75-80.
[http://dx.doi.org/10.1007/s00590-002-0019-4] [PMID: 24570157]
[8] Forlin E, Guille JT, Kumar SJ, Rhee KJ. Transepiphyseal fractures of the neck of the femur in very young children. J Pediatr Orthop 1992; 12(2): 164-8.
[http://dx.doi.org/10.1097/01241398-199203000-00004] [PMID: 1552017]
[9] Cannon SR, Pool CJ. Traumatic separation of the proximal femoral epiphysis and fracture of the mid-shaft of the ipsilateral femur in a child. A case report and review of the literature. Injury 1983; 15(3): 156-8.
[http://dx.doi.org/10.1016/0020-1383(83)90003-7] [PMID: 6642623]
[10] Miller WE. Fractures of the hip in children from birth to adolescence. Clin Orthop Relat Res 1973; (92): 155-88.
[http://dx.doi.org/10.1097/00003086-197305000-00014] [PMID: 4710831]
[11] Bagatur AE, Zorer G. Complications associated with surgically treated hip fractures in children. J Pediatr Orthop B 2002; 11(3): 219-28.
[PMID: 12089498]
[12] Forlin E, Guille JT, Kumar SJ, Rhee KJ. Complications associated with fracture of the neck of the femur in children. J Pediatr Orthop 1992; 12(4): 503-9.
[http://dx.doi.org/10.1097/01241398-199207000-00017] [PMID: 1613096]
[13] Varshney MK, Kumar A, Khan SA, Rastogi S. Functional and radiological outcome after delayed fixation of femoral neck fractures in pediatric patients. J Orthop Traumatol 2009; 10(4): 211-6.
[http://dx.doi.org/10.1007/s10195-009-0072-4] [PMID: 19936885]
[14] Bali K, Sudesh P, Patel S, Kumar V, Saini U, Dhillon MS. Pediatric femoral neck fractures: our 10 years of experience. Clin Orthop Surg 2011; 3(4): 302-8.
[http://dx.doi.org/10.4055/cios.2011.3.4.302] [PMID: 22162793]

Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


Browse Contents



Webmaster Contact: info@benthamopen.net
Copyright © 2019 Bentham Open