Early versus late treatment of paediatric femoral neck fractures:
a systematic review and meta-analysis
Manaf H. Younis
Received: 22 February 2018 /Accepted: 18 May 2018
SICOT aisbl 2018
Purpose Femoral neck fractures in children represent less than 1% of all paediatric fractures. Osteonecrosis of the femoral head is
one of the devastating complications of this fracture. Time to treatment is one of the most important predictors of this outcome
with no clear consensus in the literature. The aim of this study was to determine whether early treatment (< 24 hours) of pediatric
femoral neck fractures is associated with a lower rate of osteonecrosis of the femoral head compared to late treatment (> 24 hours).
Methods We searched several databases (PubMed, Embase, and Cochrane library), from January 1966 to November 2017 for
any comparative studies that evaluated early (< 24 hours) versus late (> 24 hours) treatment of paediatric femoral neck fractures.
We pooled the effect sizes using fixed effects model that compared the rate of osteonecrosis of the femoral head between children
undergoing early versus late treatment, open versus closed reduction, displaced versus non-displaced and different Delbet type
femoral neck fractures. Descriptive and qualitative data was also extracted.
Results Of the 391 articles identified, six studies (prospective and retrospective cohort studies) were eligible for the meta-
analysis, with a total of 231 paediatric femoral neck fractures. The pooled odds ratio (OR) for osteonecrosis of the femoral head
did not show any statistically significant difference between early (< 24 hours) versus late (> 24 hours) treatment (OR = 1.19,
95% CI 0.56, 2.51, I
= 23.6%), nor between open versus closed reduction of paediatric femoral neck fractures (OR = 1.62, 95%
CI 0.82, 3.22, I
= 19.57%). Displaced and Delbet type I/II femoral neck fractures were 3.8 (OR = 3.81, 95% CI 1.49, 9.78, I
0.00%) and 2.4 (OR = 2.43, 95% CI 1.28, 4.61, I
= 0.57%) times more associated with osteonecrosis of the femoral head
compared to non-displaced and Delbet type III/IV fractures respectively.
Conclusions The cumulative evidence at present does not indicate an association between the time to treatment or method of reduction
of femoral neck fractures in children and the risk of osteonecrosis of the femoral head. However, initial expedient treatment of femoral
neck fractures in children should always remain the rule especially for displaced and Delbet type I/II femoral neck fractures.
Level of evidence II/III
Keywords Hip fractures
Femur neck fractures
Femoral neck fractures in children are rare and represent less
than 1% of all paediatric fractures [1–4]. These fractures are
usually caused by high energy trauma such as falling from a
height or motor vehicle accidents. Although most paediatric
fractures can be treated conservatively, this type of fracture
requires a different approach as it has complications with dev-
astating sequelae that may have lifelong adverse effects [5–7].
Common complications following paediatric femoral neck
fractures include osteonecrosis of the femoral head, coxa vara,
and premature physeal closure of the proximal femoral physis.
Of these, osteonecrosis of the femoral head is the most trou-
blesome complication and difficult to manage [1–8]. Once
osteonecrosis of the femoral head occurs in children, there is
no effective treatment and the outcome is poor. Hence, the best
treatment is to prevent its occurrence.
The rate of osteonecrosis of the femoral head following
femoral neck fractures in children varies between studies
and has been reported to range from 0 to 92% [5, 6, 9].
* Talal Ibrahim
Department of Surgery, Section of Orthopedics, Hamad General
Hospital, Doha, Qatar
Department of Surgery, Section of Orthopedic Surgery, Sidra
Medical & Research Center, PO Box 26999, Doha, Qatar