Keywords
Athletic Trainers in Physician Practice Society Meeting and Conference 2025
Abstract
Background: The patient sustained a femoral neck fracture at the age of 13 after slipping and falling in his home. He was seen in the Emergency Department the same day and underwent a closed reduction and percutaneous pinning procedure the following morning. Ten weeks after returning to full weightbearing, and 13.5 weeks after his initial fracture, he developed stress fractures of the medial distal femoral and proximal tibial metaphyses. He experienced gradual worsening of hip pain and difficulty with ambulation between 11 to 13 months post-closed reduction and percutaneous pinning (CRPP). Avascular necrosis and collapse of the femoral head was identified on radiograph, and he underwent hardware removal. Magnetic resonance imaging was performed to assess the extent of the lesion for surgical planning. It was determined that the defect was too large to be a candidate for a femoral head allograft transplant, and it was recommended he undergo a total hip replacement. His total hip arthroplasty (THA) was performed 5 months following his hardware removal and 19 months after his initial fracture. Interventions and Timeline: Table. Diagnostics: Figure 1 and Figure 2. Uniqueness: The overall incidence of avascular necrosis after a proximal femoral neck fracture in pediatric patients aged 0 to 18 is 22%. However, this has been found to vary based on the Delbet fracture type and age of the patient. This patient met both criteria for higher risk factors of developing avascular necrosis (AVN), which are aged over 12 and a Delbet Type I or II proximal femoral neck fractures They identify 61% increased likelihood in those older than 12 when compared to their younger counterparts and 32% increased risk in Types I and II when compared to Types III and IV. The overall incidence following a Type II fracture, as is the case for this patient, is 32%, and the incidence for a Type I fracture is 45%. This study found no correlation between AVN development and reduction type or treatment time within 24 hours. The overall conversion rate from femoral neck CRPP to THA in adults is 10.4% at an average of 11.2 months post-operatively. Furthermore, it is suspected that there is a higher incidence of conversion in younger adults when compared to their older counterparts, so it may be reasonable to assume the same in the pediatric population. After discovering the femoral head collapse, this patient underwent a hardware removal in a staged fashion before his THA, similar to previously reported literature. Removing retained pediatric hardware at the time of THA has resulted in increased intraoperative time, length of stay, need for bone grafting, risk of intraoperative complications/fracture, loosening of the implants, and ultimate need for revision. The recommendation is to wait 3 to 6 months between hardware removal and THA. Outcomes: The patient in this case is currently 7.5 months post THA and is doing well. He rates his pain at a 0/10 and is no longer taking oral analgesics or using a crutch for ambulation. Key points moving forward are consistent follow-up appointments to monitor deterioration of the implants. Since the expected lifespan of the artificial joint ranges from 10 to 20 years, in the pediatric patients, it is extremely important to replace poly lining before becoming metal-on-metal, avoiding a potential revision. Additional concerns in the pediatric THA patient include a future leg length discrepancy as the patient continues to grow and mature. The current plan of care in the event of an acquired leg length discrepancy is to manage with shoe lifts/inserts as long as possible, and if needed, replace the femoral stem/neck with a longer one.
Recommended Citation
Fisher, K A.
(2025)
"Adolescent Femoral Neck Fractures: A Case Study on Initial Surgical Intervention, Avascular Necrosis Development, and Subsequent Total Hip Arthroplasty,"
Clinical Practice in Athletic Training: Vol. 8:
Iss.
1, Article 15.
Available at:
https://scholars.indianastate.edu/clinat/vol8/iss1/15
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