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CASE REPORT

Traumatic Simultaneous Bilateral Fractures Of Femoral Neck In Children-Mechanism Of Injury

*Pankaj Kumar, G.K.Singh, M.P.Singh

*Department of Orthopaedics,
B.P.Koirala Institute of Health Sciences, Dharan, Nepal.

Address for Correspondence

Dr Pankaj Kumar
Assistant Prof., Department of Orthopedics,
B.P.Koirala Institute of Health Sciences, Dharan, Nepal
Phone: +97-25-525555-3260,2016
Fax:+977-25-520251
E-mail:drpankaj06@yahoo.co.in

Abstract

We report the third case in medical literature reviewed of bilateral fracture neck femur in a young female child and describe the possible mechanism.
Key words: Fracture neck of femur, Bilateral, Mechanism of injury

J.Orthopaedics 2006;3(3)e5

Introduction:

Bilateral fractures of the femoral neck in children mostly occur due to high - energy impact. [4] These fractures involve mostly osteopenic bones of the elderly. Bilateral femoral neck fractures in a disease-free bone of a child are very rare. [2] We retrieved only two cases from medical literature where the mechanism is described in detailed.  We report the third such case and suggest a possible mechanism, different to the one described in literature, which was possibly operating in this case.

Case report: 

An 11-year-old female reported with a fall from the tree 20 ft height. Firstly the right thigh struck a branch before she landed on the ground with the left lower limb extended.  She lost consciousness for a few minutes and was brought to the emergency department of BPKIHS 4 hours following injury. At the time of admission she was complaining of difficulty in breathing, abdominal pain and pain around bilateral hip region. On examination chest compression test was positive, abdomen was soft and the abdomen was tender and mildly distended.  On auscultation of chest bilateral air entry was equal with normal vesicular breathing without additional sounds.  Bowel sounds were normally heard. USG revealed collection in peri-splenic area, pelvic region and free fluid in the left pleural space. X-ray of the abdomen revealed dilated small bowel loop and X-ray of hip joints revealed bilateral fracture neck of femur. (Fig 1) The patient was kept on conservative management with Ryles tube and bilateral skin traction, upon which he recovered slowly over a period of 10 days. After that she underwent opened reduction and internal fixation of her fractures with canulated cancellous screws. Bilateral skin traction was applied for 3 weeks for immobilization and gradual active assisted hip mobilization on bed was started after 1 week. Both the fractures united completely at 14 weeks and the patient returned to full activity at 20 months. At 30 months later there were no signs of avascular necrosis of the head of femur.

Discussion :

Fractures of the femoral neck in children are rare and such cases result from severe trauma. [4] Although cases of simultaneous bilateral fractures of the femoral neck are reported in young adults and elderly with osteopenic bones, there have been two such cases reported in children having normal bones. Most of the concurrent bilateral fractures are caused by violent trauma resulting from electric shock, either accidental or during electro-convulsive therapy. [1], [3], [5] High-energy trauma is the accepted mechanism of injury for childhood femoral neck fractures. [1] This usually occurs following a fall from a height (a tree, ladder or a wall). In such cases, initially they fall on edge of the roof or on branch of tree fracturing one neck of femur before falling to the ground to fracture the other. During this process possibly one limb is forced into abduction, extension and external rotation and a further continuation of these forces causes the neck to break. This mechanism would normally result in an obturator type anterior dislocation of the hip6 but the tight iliopsoas from hip extension and the tight rectus femoris from knee flexion along with the anterior capsule and the Y shaped ligament of Bigelow prevent this from happening. Thus, femoral necks fracture rather than an anterior dislocation of the hip results. Following this the other side impacts the ground causing the classical indirect flexion, adduction external rotation force at hip to fracture the neck of the opposite side. Fig 2.

Reference :

  1. Atkinson R, Kinnett JG, Arnold WD. Simultaneous fractures of both femoral necks: review of the literatures and report of two cases. Clin Orthop Rel Res 1980; 152:2847.

  2. Ashish Upadhyay, Lalit Maini, Sumit Batra, et al Simultaneous bilateral fractures of femoral neck in children-mechanism of injury.JINJ 2045 13

  3. Chadha M, Balain B, Maini L, et al. Spontaneous bilateral displaced femoral neck fractures in nutritional osteomalacia: a case report. Acta Orthop Scand 2001; 72(1): 946.

  4. Canale ST, Beaty JH, Pelvic and hip fractures. In: Rockwood CA, Wilkins KE, Beaty JH, editors. Fractures in children.Philadelphia: Lippincot-Raven; 1996. p. 1149.

  5. Nanda S, Mohanti RC. Bilateral fracture of the neck of the femur. J Indian Med Assoc 1968; 51:1856.Shaheen MA, Sabet NA. Bilateral simultaneous fracture of the femoral neck following electrical shock. Injury 1984; 16:134.

  6. Toms AD, Williams S, White SH. Obturator dislocation of the hip. J Bone Joint Surg [Br] 2001; 83-B: 1135.

 

This is a peer reviewed paper 

Please cite as : Pankaj Kumar: Traumatic Simultaneous Bilateral Fractures Of Femoral Neck In Children-Mechanism Of Injury

J.Orthopaedics 2006;3(3)e5

URL: http://www.jortho.org/2006/3/3/e5

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