Infected nonunion fracture neck of femur with severe hip joint destruction in a child

Introduction

Femoral neck fractures in children are uncommon but carry a significant risk of complications, particularly when complicated by infection or delayed union [1] Palocaren, T. (2018). Femoral neck fractures in children: a review. Indian journal of orthopaedics, 52(5), 501-506.. Pediatric femoral neck fractures are rare and associated with a high risk of complications, particularly when infection and nonunion developed [2] Stone, J. D., Hill, M. K., Pan, Z., Novais, E. N. (2015). Open reduction of pediatric femoral neck fractures reduces osteonecrosis risk. Orthopedics, 38(11), e983-e990.. Septic arthritis, epiphysitis, and chronic osteomyelitis are rare but devastating outcomes that may result in joint destruction and limb shortening [3] Pandey, P. K., Pawar, I., Gupta, J. (2016). Physeal separation and complete resorption of femoral head associated with chronic osteomyelitis of femoral diaphysis in a young child: rare case report. Journal of Pediatric Orthopaedics B, 25(6), 529-532..

This case illustrates a complex course of an infected nonunion in a child and explores the challenges of treatment, especially when advanced therapies such as orthobiologics are declined.

Case presentation

A 10-year-old male presented with persistent left hip pain, limited mobility, sinus infection discharge, and limb length discrepancy. Over a year prior, he had sustained a fracture of the neck of the left femur after falling from a height. The fracture was treated with internal fixation, which later became infected. The implants were removed, but the patient’s infection persisted.

Clinical Findings and Imaging

Limb examination: Pain in the groin area that occasionally radiate to the medial side of thigh, limping gait, Left lower limb 4 cm shortening due to resorption of proximal femur and growth disturbance, Limitation of Lt hip motion.

X-ray (AP and lateral views) (Figure 1): showed Widening of the hip joint space, Resorption of the femoral head and neck, Proximal migration of the greater trochanter and Cavitation and sclerosis of upper femur; suggestive of chronic osteomyelitis.

MRI: Confirmed findings consistent with septic arthritis, epiphysitis, and chronic osteomyelitis.

Laboratory Investigations

CBC: W.B. Cs= 19.000, ESR= 35 and CRP= 18, Renal and liver function tests: Normal, HbA1c and fasting blood glucose: Normal, Vitamin D, calcium, alkaline phosphatase: Normal, Blood and synovial fluid cultures: pseudomonas bacterial infection resistant to many antibiotics, Plasma protein examination showed hypoalbuminemia.

Management

The patient underwent: Extensive surgical debridement and lavage, correction of hypo-albuminemia, Empirical post culture sensitive IV antibiotics, Valgus osteotomy of the proximal femur to improve joint mechanics and compensate for deformity (Figure 2).

The orthopedic team also considered orthobiologics (e.g., bone graft substitutes, growth factors, or stem-cell-based therapies) as an adjunct to enhance bone healing. However, the family declined all these interventions.

Also, due to significant limb shortening, a custom-made orthopedic shoe was prescribed to compensate for the length discrepancy and improve gait.

Detection of sequelae

As femur head is purely cartilaginous more susceptible to direct destructive activity of pus and inflammatory products, also increased intra-capsular pressure complicated by avascular necrosis of femur head, these lead to absorption of femur head and neck resulting in sever shortening and disability.

Outcome and Follow-Up

Following surgery and rehabilitation, the patient reported improvement in pain and joint mobility. Inflammatory markers normalized, and infection was controlled. He remains under orthopedic and physiotherapy follow-up. While limb shortening persists. He is currently managed non-surgically with a shoe lift. Future surgical plan for limb length discrepancy may be considered as the child grows.

Discussion

This case reflects a rare but serious cascade of complications from pediatric femoral neck fractures, emphasizing: The risk of infection and nonunion following internal fixation [5] Kurahashi, S., Takegami, Y., Tokutake, K., Nakashima, H., Mishima, K., Yamauchi, K., Imagama, S. (2024). Risk factors for nonunion in femoral neck fracture patients with internal fixation: A multicenter (TRON group) retrospective study. Journal of Orthopaedic Science.. The devastating consequences of chronic joint infection in a skeletally immature child, including growth plate involvement (epiphysitis), osteomyelitis, and femoral head and neck resorption [6] Malik, J., Khaled, S. (2023). Disturbance of growth in pediatric patients due to osteomyelitis caused by growth plate infection. Cureus, 15(12)..

Many surgical interventions were described to overcome the resorption of femoral head and neck like Harmon arthroplasty of greater trochanter (Figure 4), L’Epsicopo arthroplasty, Modified Albee arthroplasty (Figure 5), and others [7], Li, X. D., Chen, B., Fan, J., Zheng, C. Y., Liu, D. X., Wang, H., Du, S. X. (2010). Evaluation of the modified Albee arthroplasty for femoral head loss secondary to septic arthritis in young children. JBJS, 92(6), 1370-1380.[8] Benum, P. (2011). Transposition of the apophysis of the greater trochanter for reconstruction of the femoral head after septic hip arthritis in children: 4 children followed for more than 15 years. Acta orthopaedica, 82(1), 64-68..

The challenge of managing limb length discrepancy, especially when growth potential remains.

The use of orthobiologics—which may include platelet-rich plasma (PRP), bone morphogenetic proteins (BMPs), or stem cells—was considered to promote healing. However, due to family refusal, this modality was not utilized, potentially affecting long-term outcomes. The most important thing is the correlation of hypo-albumeneamia [12], Moreno-Garcia, A., Rodriguez-Merchan, E. C. (2022). Orthobiologics: current role in orthopedic surgery and traumatology. Archives of Bone and Joint Surgery, 10(7), 536.[13] Costa, F. R., Pires, L., Martins, R. A., Santos, M., Santos, G. S., Lana, J. V., Lana, J. F. (2025). Orthobiologics Revisited: A Concise Perspective on Regenerative Orthopedics. Current Issues in Molecular Biology, 47(4), 247..

Conclusion

Pediatric femoral neck fractures complicated by infection require multidisciplinary care. Early intervention, infection control, and reconstructive techniques like valgus osteotomy can salvage joint function. When advanced treatment like orthobiologics is declined, supportive options such as orthopedic shoe modification may play an essential role in maintaining mobility and quality of life.

Classification used and Plan of management in septic hip cases