Iatrogenic femoral neck fractures or separation of the proximal femoral epiphysis during closed reduction of irreducible femoral head fracture–dislocations in children: a review of 12 cases

Objectives: This study aimed to analyze the radiologic characteristics of irreducible pediatric femoral head fracture-dislocations to prevent potential iatrogenic femoral neck fractures (FNF) or separation of the proximal femoral epiphysis (SPFE). Methods: This is a retrospective review of patients who were skeletally immature and diagnosed with traumatic hip dislocations combined with femoral head fractures. The collected data included patient demographics, fracture classification, fragment ratio, combined injuries, urgent reductions, treatment strategies, complications, and final outcomes. Results: We treated 12 patients with femoral head fractures and dislocations; 11 out of 12 patients underwent urgent closed reduction (91.7%). Six of the patients failed closed reduction and experienced FNF (n = 2, 33.3%) or SPFE (n = 4, 66.7%). Five patients presented with avascular necrosis of the femoral head after open reduction with internal fixation via a surgical hip dislocation approach, and two patients required further surgical treatment. Analysis of radiographs and computed tomography (CT) scans of irreducible femoral head fracture-dislocations revealed that the fractured femoral head was perched on the sharp angle of the posterior wall of the acetabulum, with a fragment ratio of 18-27%. After recognizing the irreducibility, one case with a fragment ratio of 26% underwent immediate open reduction without further attempts at closed reduction. This procedure preserved the natural hip joint, preventing FNF and SPFE. Conclusions: For pediatric patients with irreducible femoral head fracture-dislocation injuries and a fragment ratio greater than 10%, repeated or forceful closed reduction may result in iatrogenic FNF or SPFE. Examining plain radiographs and CT images carefully before attempting reduction may help determine the safest treatment strategy.