Femoral Neck Fractures

Key Points:


Fractures of the femoral neck and includes fractures that involve the proximal femoral epiphysis, femoral neck, and intertrochanteric region of the femur.  

Delbet classified femoral neck fractures into four types that provides guidance for treatment and prognosis (Figure 1):
Type 1--transepiphyseal fractures
Type 2--transcervical fractures
Type 3--cervicotrochanteric fractures
Type 4--intertrochanteric fractures 

Figure 1: Delbet classification: A) Type I, B) Type II, C) Type III, D) Type IV



Femoral neck fractures account for <1% of all fractures in pediatric patients and <1% of all hip fractures (Canale 1977, Boardman 2009, Ratliff 1962).

Clinical Findings:

These patients are unable to bear weight on the injured extremity.  They may have a shortened and externally rotated extremity, and the fracture may be associated with other polytrauma injuries (head injuries, abdominal injuries, etc).

Imaging Studies:

Plain radiographs are the primary imaging modality to diagnose and classify a pediatric femoral neck fracture. When attempting a cross-table lateral radiograph, care should be taken to move the uninjured limb so as not to significantly displace the fracture on the injured side.  CT or MRI may play a role in concurrent femoral neck fracture-dislocations to better define the pattern of injury.(Lee 2010) 


Treatment ranges from closed reduction and spica casting to open reduction and internal fixation.  Capsulotomy has been recommended to evacuate the intracapsular hematoma and potentially decrease the risk of AVN.  Treatment is determined by the Delbet classification, displacement, and the age and size of the patient.

Type 1 Fractures (Transepiphyseal) Type 2 Fractures (Transcervical) and Type 3 Fractures (Cervicotrochanteric)   Type 4 Fractures (Intertrochanteric) Post-operative immobilization is based on fracture type, patient age, and treatment.  A period of 8-10 weeks in a spica cast is recommended for those children who cannot be compliant with non-weightbearing or partial weightbearing.  The older adolescent with rigid fixation can begin partial 
weightbearing within 2 weeks.(Swiontowski 2009)


Avascular Necrosis

Rates range from 0-92%.(Riley 2014) A meta-analysis found an osteonecrosis rate of 38% for Type 1 fractures, 28% for Type 2 fractures, 18% for Type 3 fractures, and 5% for Type 4 fractures.(Moon 2006)  Another recent study of 44 patients showed rates of 50%, 28%, 8%, and 10% for fracture types 1-4, respectively.(Riley 2014) 

Delayed union/Non-union

Delayed or nonunion may be related to treatment method.  Internal fixation is preferred, when possible, and can reduce nonunion rates.(Bali 2011) The reported incidence is 1-10% of fractures.(Boardman 2009) Subtrochanteric valgus osteotomy without the need for bone graft converts the force across the fracture from shear to compression and is the preferred treatment for femoral neck nonunions.(Canale 1977)

Premature Physeal Closure

This may not cause significant limb length inequality due to the robust nature of the distal femoral physis, however the magnitude of the discrepancy will depend upon the age of the child at the time of the physeal arrest.(Hamilton 1961) Physeal closure may be caused by the injury or due to fixation that crosses the physis.  A partial growth arrest may cause coxa vara or valga.

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