Treatment of Displaced Femoral Neck Fractures in Children: Mid-Term Outcomes and Predictors of Failure.

Abstract

Displaced femoral neck fractures in children are rare but carry significant risk for complications such as avascular necrosis (AVN), nonunion, and malunion. Although adult literature increasingly supports closed reduction when adequate alignment is achieved, the pediatric literature lacks consensus on optimal management. This study evaluates whether the quality of reduction, regardless of open or closed technique, predicts adverse outcomes in pediatric displaced femoral neck fractures. We retrospectively reviewed 56 patients (ages 2 to 18) with displaced Delbet type II or III femoral neck fractures treated surgically at a single pediatric trauma center from 2000 to 2022. Fractures were classified radiographically, and the quality of postoperative reduction was assessed independently by 2 fellowship-trained orthopaedic surgeons. The primary outcome was a composite of adverse events including AVN, nonunion, malunion, fixation failure, SCFE, and infection. Survival analyses and Cox proportional hazard models were used to evaluate associations between reduction quality and outcomes. Anatomic reduction was achieved in 55% of patients and was more common after open reduction than closed reduction (71% vs. 29%, P=0.001). Patients with anatomic reductions had a significantly lower hazard of adverse events (HR: 0.21; 95% CI: 0.06-0.72; P=0.013) and longer event-free survival (RMST: 6.1 vs. 3.0 y, P=0.001). Type of reduction (open vs. closed) and preoperative radiographic parameters did not independently predict adverse outcomes. Early surgery (<12 h) did not show benefit and was associated with lower odds of achieving anatomic reduction. Anatomic reduction, regardless of technique, is the strongest predictor of favorable outcomes after pediatric displaced femoral neck fracture. Open reduction should be pursued when closed methods fail to achieve anatomic alignment. Radiographic injury patterns and time to surgery were not independently predictive of adverse outcomes. These findings underscore the importance of prioritizing reduction quality to optimize long-term hip preservation in children. Level III-retrospective comparative study.