Closed reduction maneuvers
1. Introduction
Closed reduction plays a much more limited role in the management of pediatric femoral neck fractures than it does in the management of adult femoral neck fractures.
Pediatric fractures are more commonly high energy injuries and vascularity of the proximal femur is uniquely vulnerable in children.
Any reduction maneuver must be very gentle to avoid damage to retinacular vessels on the posterior femoral neck. Additionally, an anatomical reduction should be obtained to avoid pressure or kinking of the vessels. Accordingly, gentle open reduction via a safe approach is often preferred.
2. Traction
Gentle in-line traction of approximately 1/6 of the child's body weight can be applied to the limb either by the surgeon or by the fracture table.
If gentle traction does not reduce the fracture, consideration should be given to open reduction.
One further cautious attempt at closed reduction may be attempted.
3. Traction, flexion, external rotation
The key element of the closed reduction maneuver is that gentle, sustained traction be applied in-line with the femoral neck, with the hip flexed and externally rotated to untwist and relax the spiral fibers of the hip capsule. This is referred to as the Flynn maneuver.
4. Internal rotation, extension
After reducing the fracture, the hip is internally rotated, gradually extended and abducted to maintain reduction. This tightens the spiral fibers of the capsule and “locks” the reduction.
All these movements should be performed very gently in children.
Note: Repeated attempts at reduction should not be made.
5. Fixation
In cases where an anatomical reduction is achieved following these gentle reduction maneuvers, surgical stabilization is mandatory.
Fractures that remain impacted, unstable, or significantly displaced, are better treated with open reduction than with repeated, or vigorous, attempts at closed reduction.
