Ratliff's 1962 landmark collected series of 71 children with femoral neck fractures — followed up to 20 years across 43 British centres — characterizes the natural history and complication rates of this rare injury. It proposes the Ratliff classification system that still guides management today. The study defines which fracture types, treatment strategies, and AVN patterns predict good versus poor outcomes.
When a child presents after high-energy trauma with a femoral neck fracture, the default instinct to cast and observe is wrong for displaced injuries. Before this paper, manipulative reduction and plaster spica was commonly used for displaced fractures. Ratliff showed it failed to maintain reduction in 15 of 19 patients — a failure rate that should end the practice.
For displaced fractures in children over 10, attempt manipulative reduction and internal fixation. If adequate reduction cannot be achieved, or if the child is under 10, primary subtrochanteric osteotomy is the preferred alternative. Non-union did not occur after either of these strategies.
Counsel every family that AVN occurs in 42% of cases regardless of treatment, can develop even after undisplaced fractures, and is impossible to predict. Always appears within one year of injury. The Ratliff AVN pattern matters prognostically: Type I (diffuse collapse) always ends badly, while Types II and III can have good outcomes despite radiographic changes.
Ratliff's 1962 landmark collected series of 71 children with femoral neck fractures — followed up to 20 years across 43 British centres — characterizes the natural history and complication rates of this rare injury. It proposes the Ratliff classification system that still guides management today. The study defines which fracture types, treatment strategies, and AVN patterns predict good versus poor outcomes.
When a child presents after high-energy trauma with a femoral neck fracture, the default instinct to cast and observe is wrong for displaced injuries. Before this paper, manipulative reduction and plaster spica was commonly used for displaced fractures. Ratliff showed it failed to maintain reduction in 15 of 19 patients — a failure rate that should end the practice.
For displaced fractures in children over 10, attempt manipulative reduction and internal fixation. If adequate reduction cannot be achieved, or if the child is under 10, primary subtrochanteric osteotomy is the preferred alternative. Non-union did not occur after either of these strategies.
Counsel every family that AVN occurs in 42% of cases regardless of treatment, can develop even after undisplaced fractures, and is impossible to predict. Always appears within one year of injury. The Ratliff AVN pattern matters prognostically: Type I (diffuse collapse) always ends badly, while Types II and III can have good outcomes despite radiographic changes.