Ipsilateral femoral neck and shaft fracture in children: a report of two cases and a literature review
© The Author(s) 2012
Received: 21 December 2010
Accepted: 13 March 2012
Published: 5 May 2012
Concomitant ipsilateral fractures of the neck and shaft of the femur in children are rare. The most recent report in this context found a total of only nine reported cases (<12 years of age) following a search of the indexed English literature. These injuries occur in children due to high-velocity trauma, and there is no generally accepted method of treatment. We report three additional cases from the literature and two cases of our own. In our cases, one had a residual 10° varus deformity at the subtrochanteric level in the femur, but this did not affect hip function. Another patient exhibited a limp at final follow-up due to leg length discrepancy, and peroneal nerve palsy at the time of injury. We advocate operative stabilization of the femoral shaft fracture first to reduce the risk of further displacement and simplify the subsequent reduction of the femoral neck. The series shows that these rare injuries have a poor prognosis, with high rates of incidence of avascular necrosis, coxa vara, and leg length discrepancy.
Concomitant ipsilateral fractures of the neck and shaft of the femur in children are rare. The authors of the most recent report in this context found that only nine cases (<12 years of age) have been reported to date, including two of their own cases; the other seven cases were found by searching the indexed English literature . Only one or two cases are reported in each of the works they found in the literature [1–7]. These injuries occur in children due to high-velocity trauma, and there is no universally accepted method of treatment . We report two additional cases with such a combination of injuries as well as three additional reports [9–11] found in the literature. Our study showed that there is a relatively high complication rate with transepihyseal or transcervical femoral neck fractures, so we disagree with the opinion that a symbiotic effect during the time of injury results in a lower incidence of complications . The present study was performed after obtaining informed consent from the patients’ parents or guardians.
Femoral neck fx
Present series (case 1)
Cervicotrochanteric (Delbet type III; AO type II)
1 screw & 3 Kirshner wires for the neck fracture, 5-hole plate and 3 screws for the shaft fracture
Good Ratliff score. Clinically good with a 10° varus deformity at the subtrochanteric level in the femur
Present series (case 2)
Intertrochanteric (Delbet type IV; AO type II)
Lateral condyle fracture of the right humerus, distal radius fracture of left wrist fx, subdural hemorrhage of brain, ipsilateral sciatic nerve palsy (peroneal division)
2 screws for the neck fracture, 6-hole plate and screws for the shaft fracture
Good Ratliff score. Clinically good except for only a slightly short neck and a 1.5 cm leg length discrepancy
Transepiphyseal (Delbet type Ib; AO epiphyseal type 1)
Open reduction and internal fixation with 2 smooth Kirshner wires for neck fracture, hip spica cast. A-frame orthosis for the capital epiphysis
Clinically good, with some coxa vara and premature physeal closure of the medial segent at the 2-year follow-up
Fall from height
Transepiphyseal (Delbet type Ia; AO epiphyseal type I)
Closed reduction and hip spica cast for the neck fracture, and 4-hole plate screws for the shaft fracture
Excellent, except for some coxa vara
Cervicotrochanteric (Delbet type III; AO type II)
1 screw and 2 pins for the neck fracture on day 23, conservative for the distal physeal fracture
Aspherical head, coxa vara, short femoral neck, reversed articulotrochantric distance. Valgus and recurvatum deformity of the distal femur
Femoral neck fractures in children are well known for their sinister nature and potential for complications, especially avascular necrosis, which poses the most serious problem and has been reported to have a variable incidence [15, 16, 18–22]. It depends on several factors, such as the degree of initial displacement [15, 17–19, 21, 23], the type of fracture [15, 24, 25], and the timing of surgery [16, 24].
Upon reviewing all nine cases documented by Agarwal et al. , six of the femoral neck fractures they reported were cervicotrochanteric (Delbet type III; AO type II), one was transepiphyseal (Delbet type I; AO epiphyseal type 1), another was intertrochanteric (Delbet type IV Delbet; AO type III), while the fracture type was insufficiently described to be able to establish it for the other case. The level of concomitant femoral shaft fracture was midshaft in six cases, distal third in one, and the description was insufficient to determine the level in two cases [1–7].
In this study, we have reported an additional five cases (two from our experience and three more reports fould in the literature). The type of fracture neck femur was transepiphyseal (Delbet type I; AO epiphyseal type I) in two cases, cervicotrochanteric (Delbet type III; AO type II) in two cases, and intertrochanteric (Delbet type IV; AO type III) in one case. If all fourteen cases are considered together, the most common type of femoral neck fracture, when associated with ipsilateral femoral shaft injury, is Delbet type III (AO type II) fracture (eight cases).
Although it is not easy to define the mechanism of trauma, we believe that the mechanism of injury must be high-energy impact at both fracture sites simultaneously. We do not think that sequential application of high-energy forces after a time interval can produce another fracture on top of an already unstable previous fracture.
Various treatment modalities have been tried for these injuries—operative, conservative, or a combination of both. Although good results have been reported with all of these treatment modalities in the literature [1–7], the authors advocate operative stabilization of these injuries to reduce the risk of further displacement of the fracture and allow early mobilization [1, 11]. However, we believe that open reduction and internal fixation of the femoral shaft fracture is the only treatment that permits control over and avoids worsening of the ipsilateral femoral neck fracture; we do not favor it solely because it permits early mobilization. We applied a hip spica cast in both of our cases to promote stability at the fracture site.
We recommend prior fixation of the femoral shaft fracture in these injuries, without attempting to reduce the femoral neck fracture initially, as it provides for more easy subsequent manipulation, reduction, and fixation of the ipsilateral femoral neck fracture. In both of our cases, we fixed the femoral shaft fracture with a plate and screw, and followed this with closed reduction and internal fixation of the femoral neck fracture. However, in one case (case 1), reduction of the subtrochanteric fracture was lost due to proximal screw back-out resulting from inadequate fixation of the proximal fragment, which in turn led to a 10° varus deformity of the proximal femur. In this case, we should have considered the distance between the two fractures to be a prognostic factor, and the possibility of using a low-profile plate that can be modeled in the proximal part to allow introduction of a screw through the proximal hole of the plate into the femoral neck if the two fractures are too close together. We do not need absolutely stable osteosynthesis, because in children younger than ten years it is always advisable to create a spica cast.
At the 2-year follow-up, there was a residual 10° varus deformity of the proximal femur without leg length discrepancy, although leg length discrepancy was noted as being a problem in case 2; this could have occurred after plate and screw fixation when treating the femoral shaft fracture in the child.
Agarwal et al.  also noted that a combination of ipsilateral femoral neck and shaft fracture in children had a low incidence of complications. They proposed that the fractures that occur at the two sites in the same limb probably have a symbiotic effect, and that the impact energy was distributed at the time of the initial trauma, thus preventing extreme damage to either of the fracture sites. However, in their report, they only noted cervicotrochanteric and intertrochanteric types of femoral neck fracture, which are less prone to avascular necrosis than the transepiphyseal or transcervical types. In our review of an additional five cases, two had avascular necrosis of the capital epiphysis: one was a transepiphyseal fracture with major displacement (Delbet type Ib)  which was treated with open reduction and internal fixation, while the other was a cervicotrochanteric fracture  diagnosed on day 9 and operated on day 23 after the initial injury. We do not agree with the view that a symbiotic effect at the time of initial trauma plays a significant role in the prognosis of these injuries, because our study showed relatively high complication rates with transepiphyseal and transcervical femoral neck fractures, which were not presented in the previous literature.
We believe that prior fixation of the femoral shaft fracture in these injuries simplifies the subsequent manipulation, reduction, and fixation of the ipsilateral femoral neck fracture, and that the results of these injuries depend on the severity of the initial trauma, the fracture type, and the timing of surgery.
Conflict of interest
I obtained informed consent from the patient’s parent and parent approved the publication of this case report.
This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.
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