International Orthopaedics

, Volume 43, Issue 3, pp 677–685 | Cite as

Early versus late treatment of paediatric femoral neck fractures: a systematic review and meta-analysis

  • Nedal AlKhatib
  • Manaf H. Younis
  • Abdelsalam Hegazy
  • Talal IbrahimEmail author
Original Paper



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).


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.


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, I2 = 23.6%), nor between open versus closed reduction of paediatric femoral neck fractures (OR = 1.62, 95% CI 0.82, 3.22, I2 = 19.57%). Displaced and Delbet type I/II femoral neck fractures were 3.8 (OR = 3.81, 95% CI 1.49, 9.78, I2 = 0.00%) and 2.4 (OR = 2.43, 95% CI 1.28, 4.61, I2 = 0.57%) times more associated with osteonecrosis of the femoral head compared to non-displaced and Delbet type III/IV fractures respectively.


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



Hip fractures Femur neck fractures Pediatrics Avascular necrosis Osteonecrosis Meta-anlysis 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.


  1. 1.
    Ratliff AH (1962) Fractures of the neck of the femur in children. J Bone Joint Surg Br 44:528–542CrossRefGoogle Scholar
  2. 2.
    Hamilton CM (1961) Fractures of the neck of the femur in children. JAMA 178:799–801CrossRefGoogle Scholar
  3. 3.
    Davison BL, Weinstein SL (1992) Hip fractures in children: a long-term follow-up study. J Pediatr Orthop 12:355–358CrossRefGoogle Scholar
  4. 4.
    McCarthy J, Noonan K (2010) Fractures and traumatic dislocations of the hip in children. In: Beaty JH, Kasser J (eds) Rockwood and Wilkins’ fractures in children, 7th edn. Lippincott Williams & Wilkins, PhiladelphiaGoogle Scholar
  5. 5.
    Canale ST, Bourland WL (1997) Fracture of the neck and intertrochanteric region of the femur in children. J Bone Joint Surg Am 59:431–443CrossRefGoogle Scholar
  6. 6.
    Togrul E, Bayram H, Gulsen M, Kalacı A, Özbarlas S (2005) Fractures of the femoral neck in children: long-term follow-up in 62 hip fractures. Injury 36:123–130CrossRefGoogle Scholar
  7. 7.
    Swiontkowski MF, Winquist RA (1986) Displaced hip fractures in children and adolescents. J Trauma 26:384–388CrossRefGoogle Scholar
  8. 8.
    Morrissy R (1980) Hip fractures in children. Clin Orthop 152:202–210Google Scholar
  9. 9.
    Colonna PC (1929) Fracture of the neck of the femur in children. Am J Surg 6:793–797CrossRefGoogle Scholar
  10. 10.
    Bali K, Sudesh P, Patel S, Kumar V, Saini U, Dhillon M (2011) Pediatric femoral neck fractures: our 10 years of experience. Clin Orthop Surg 3:302–308CrossRefGoogle Scholar
  11. 11.
    Norton B, Mulligan R, Rush J, Kelly DM, Warner WC, Sawyer JR (2012) Proximal femoral fractures in children and adolescents. Curr Orthop Pract 23:429–434CrossRefGoogle Scholar
  12. 12.
    Spence D, Di Maurı JP, Miller PE, Glotzbecker MP, Hedequist DJ, Shore BJ (2016) Osteonecrosis after femoral neck fractures in children and adolescents: analysis of risk factors. J Pediatr Orthop 36:111–116CrossRefGoogle Scholar
  13. 13.
    Moon ES, Mehlman CT (2006) Risk factors for avascular necrosis after femoral neck fractures in children: 25 Cincinnati cases and meta-analysis of 360 cases. J Orthop Trauma 20:323–329CrossRefGoogle Scholar
  14. 14.
    Yeranosian M, Horneff JG, Baldwin K, Hosalkar HS (2013) Factors affecting the outcome of fractures of the femoral neck in children and adolescents: a systematic review. Bone Joint J 95:135–142CrossRefGoogle Scholar
  15. 15.
    Shrader MW, Jacofsky DJ, Stans AA, Shaughnessy WJ, Haidukewych GJ (2007) Femoral neck fractures in pediatric patients: 30 years experience at a level 1 trauma center. Clin Orthop Relat Res 454:169–173CrossRefGoogle Scholar
  16. 16.
    Cheng JC, Tang N (1999) Decompression and stable internal fixation of femoral neck fractures in children can affect the outcome. J Pediatr Orthop 19:338–343Google Scholar
  17. 17.
    Song K (2010) Displaced fracture of the femoral neck in children. J Bone Joint Surg Br 92:1148–1151CrossRefGoogle Scholar
  18. 18.
    Flynn JM, Wong KL, Yeh GL, Meyer JS, Davidson RS (2002) Displaced fractures of the hip in children. Management by early operation and immobilisation in a hip spica cast. J Bone Joint Surg Br 84:108–112CrossRefGoogle Scholar
  19. 19.
    Dhar SA, Ali MF, Dar TA, Sultan A, Butt MF, Kawoosa AA, Mir MR (2009) Delayed fixation of the transcervical fracture of the neck of the femur in the pediatric population: results and complications. J Child Orthop 3:473–477CrossRefGoogle Scholar
  20. 20.
    Varshney MK, Kumar A, Khan SA, Rastogi S (2009) Functional and radiological outcome after delayed fixation of femoral neck fractures in pediatric patients. J Orthop Traumatol 10:211–216CrossRefGoogle Scholar
  21. 21.
    Riley PM Jr, Morscher MA, Gothard MD, Riley PM Sr (2015) Earlier time to reduction did not reduce rates of femoral head osteonecrosis in pediatric hip fractures. J Orthop Trauma 29:231–238CrossRefGoogle Scholar
  22. 22.
    Panigrahi R, Sahu B, Mahapatra AK, Palo N, Priyardarshi A, Biswal MR (2015) Treatment analysis of pediatric femoral neck fractures: a prospective multicenter therapeutic study in Indian scenario. Int Orthop 39:1121–1127CrossRefGoogle Scholar
  23. 23.
    Inan U, Köse N, Omeroğlu H (2009) Pediatric femur neck fractures: a retrospective analysis of 39 hips. J Child Orthop 3:259–264CrossRefGoogle Scholar
  24. 24.
    Stone JD, Hill MK, Pan Z, Novais EN (2015) Open reduction of pediatric femoral neck fractures reduces osteonecrosis risk. Orthopedics 38:983–990CrossRefGoogle Scholar
  25. 25.
    Baysal O, Eceviz E, Bulut G, Bekler Hİ (2016) Early prediction of outcomes in hip fractures: initial fracture displacement. J Pediatr Orthop B 25:228–233CrossRefGoogle Scholar
  26. 26.
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group (2010) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 8:336–341CrossRefGoogle Scholar
  27. 27.
    Wells GA, Shea B, O’Connell D, Petersen J, Welch V, Losos M, Tugwell P (2014) The Newcastle–Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa. Accessed Nov 2017
  28. 28.
    Wallace BC, Dahabreh IJ, Trikalinos TA, Lau J, Trow P, Schmid CH (2012) Closing the gap between methodologists and end-users: R as a computational back-end. J Stat Softw 49:5CrossRefGoogle Scholar
  29. 29.
    DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7:177–188CrossRefGoogle Scholar
  30. 30.
    Higgins JPT, Green S (eds) (2011) Cochrane handbook for systematic reviews of interventions, version 5.1.0 (updated March 2011). The Cochrane Collaboration, Oxford.

Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  1. 1.Department of Surgery, Section of OrthopedicsHamad General HospitalDohaQatar
  2. 2.Department of Surgery, Section of Orthopedic SurgerySidra Medical & Research CenterDohaQatar

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