What is a femoral neck fracture?

A femoral neck fracture is a condition characterized by a break in the neck of

the femur (thigh bone).
The femur is the anatomical name given to the long bone of the thigh (figure
1). It is the largest and strongest bone in the body. The neck of the femur
refers to the part of the bone which connects the round headed ball of the hip
joint to the long shaft of the femur.
Following a fall or due to a direct blow to the hip or thigh, stress is placed on
the femur. If these forces are excessive and beyond what the femur can
withstand, a break in the neck of the bone may occur. When this occurs the
condition is known as a femoral neck fracture and can vary from a small
undisplaced fracture to a severe displaced (and / or comminuted) fracture
with obvious deformity.
Femoral neck fractures are particularly common in elderly patients who have
poor balance (i.e. are prone to falls) and have reduced bone density due to
osteoporosis.
Cause of a femoral neck fracture
Due to the strength of the femoral bone, a femoral neck fracture usually
requires a large amount of force in healthy young adults. This typically occurs
due to a fall (usually from a height, and often onto a hard surface) or due to a
direct blow to the femur such as a motor vehicle accident. The most common
clinical presentation of a femoral neck fracture is in older patients (greater
than 60) who have weakened bones due to conditions such as osteoporosis,
or sometimes, malignancy. In these cases, the injury may occur with minimal
force such as a trip, stumble or fall.
Signs and symptoms of a femoral neck fracture
Patients with a femoral neck fracture typically experience a sudden onset of
sharp, intense pain in the hip, groin, buttock or thigh at the time of injury. In
severe cases, particularly involving a displaced fracture of the femur, weight
bearing will be impossible with the patient often unable to get up off the floor
without help. In less severe cases, patients may be able to walk (typically
with a limp) and may experience symptoms that settle quickly with rest,
leaving the patient with an ache at the site of injury which may be
particularly prominent at night or first thing in the morning. Occasionally
patients may also experience symptoms in the lower back, knee, lower leg,
ankle or foot.
Patients with a femoral neck fracture may also experience swelling, bruising
and pain on firmly touching the hip region. Pain usually increases with certain
movements of the hip or knee, when sitting or when attempting to stand or
walk (particularly up hills or on uneven surfaces). Often the patient's leg will
present in a "turned-out" position and will appear to be shorter compared to
the unaffected leg. In severe femoral fractures (with bony displacement), an

obvious deformity may be noticeable. Occasionally patients may also

experience pins and needles or numbness in the hip, groin, thigh, knee, lower
leg, ankle or foot.
Diagnosis of a femoral neck fracture
A thorough subjective and objective examination from a physiotherapist is
essential to assist with diagnosis of a femoral neck fracture. An X-ray is
usually required to confirm diagnosis and assess the severity. Further
investigations such as an MRI, CT scan or bone scan may be required, in
some cases, to assist with diagnosis and assess the severity of the injury.
Treatment for a femoral neck fracture
For those femoral neck fractures that are displaced (which is usually the most
common presentation), treatment typically involves anatomical reduction (i.e.
re-alignment of the fracture via careful manipulation under anaesthetic)
followed by surgical internal fixation to stabilize the fracture (using rods,
plates, pins or screws). This may be followed by a period of rest and the use
of walking aids or crutches for a number of weeks. In elderly patients
(particularly those with osteoarthritis affecting the hip joint), prosthetic
replacement of the hip joint may be indicated. This may be followed by the
use of crutches or a walking frame for weeks to months.
For those less common, non-displaced fractures, treatment may involve the
use of crutches and/or bed rest for a number of weeks. The orthopaedic
specialist will advise the patient as to which management is most appropriate
based on a number of factors, including the location, severity and type of
femoral neck fracture.
For those patients who are not managed with hip joint replacement,
evaluation of the fracture with follow up X-rays is important to ensure the
fracture is healing in an ideal position. This is particularly important as blood
supply to the femoral head may be damaged during a fracture resulting in
significant complications with fracture healing (e.g. delayed healing, nonhealing or death of the femoral head due to lack of blood supply, known as
avascular necrosis). Once healing is confirmed, rehabilitation and mobilisation
can progress as guided by the orthopaedic surgeon and the treating
physiotherapist.
One of the most important components of rehabilitation following a femoral
neck fracture is that the patient progresses their rehabilitation with exercises
and activities which do not increase their pain (crutches are often required).
Activities which place large amounts of stress through the femur should also
be avoided, particularly excessive weight bearing activities such as running,
jumping, standing or walking excessively (especially up hills or on uneven
surfaces), lifting or carrying, or, sitting excessively. Rest from aggravating
activities allows the healing process to take place in the absence of further
damage. Once the patient can perform these activities pain free, a gradual
return to these activities is indicated provided there is no increase in

symptoms. This should take place over a period of weeks to months with
direction from the treating physiotherapist.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to cause
further damage and may slow healing or prevent healing of the femoral neck
fracture altogether.
Patients with a fractured femur should perform pain free flexibility,
strengthening and balance exercises as part of their rehabilitation to ensure
an optimal outcome. This is particularly important, as balance, soft tissue
flexibility and strength are quickly lost with inactivity. Hydrotherapy exercises
are also often indicated. The treating physiotherapist can advise which
exercises are most appropriate for the patient and when they should be
commenced.
In the stages following confirmation of fracture healing, manual "hands-on"
treatment from a physiotherapist, such as massage, trigger point release
techniques, dry needling, joint mobilisation, stretches and electrotherapy, can
assist with improving range of movement, pain and function, and assist with
hastening return to activity.
In the final stages of rehabilitation for a femoral neck fracture, a gradual
return to activity can occur as guided by the treating physiotherapist
provided there is no increase in symptoms. In younger patients, this may
involve a gradual return to running program followed by acceleration,
deceleration and change of direction drills, before commencing training and
eventually match play.
Prognosis of a femoral neck fracture
Most patients with a non-displaced femoral neck fracture make a full recovery
with appropriate management. Patients with a displaced femoral neck
fracture that requires surgical internal fixation or hip joint replacement are
unlikely to return to high level sporting activity. Depending on the severity of
the fracture (and the type of activity), return to activity or some sports
usually occurs between 3-12 months. This should be guided by the treating
physiotherapist and specialist. In patients with severe injuries involving
structural deformity or damage to other bones, soft tissue, nerves or blood
vessels, recovery time may be significantly prolonged.
Physiotherapy for a femoral neck fracture
Physiotherapy treatment is vital in all patients with a femoral neck fracture to
hasten healing and ensure an optimal outcome. Treatment may comprise:

soft tissue massage

joint mobilization

electrotherapy (e.g. ultrasound)

dry needling

the use of crutches, walking frames or other gait aids

exercises to improve strength, flexibility, core stability and balance

hydrotherapy

education

activity modification advice

a graduated return to running / activity plan

footwear advice

Other intervention for a femoral neck fracture

Despite appropriate physiotherapy and surgical management, some patients
with a femoral neck fracture do not improve adequately and may require
other intervention (this may also be required in patients who experience
some of the common complications of a femoral neck fracture such as
avascular necrosis, non-union of the bone or early onset of hip joint
osteoarthritis). The treating physiotherapist or doctor can advise on the best
course of management when this is the case. This may include further
investigations such as X-rays, CT scan, MRI or bone scan, extended periods of
non weight bearing or referral to appropriate medical authorities who can
advise on any intervention that may be appropriate to improve the fractured
femur.
Occasionally, patients with fractures that are initially managed without
surgical intervention may require surgery to stabilize the fracture and a bone
graft to aid fracture healing. Some patients with fractures that are initially
managed with surgical fixation may require joint replacement surgery
following unexpected complications.
Exercises for a femoral neck fracture
The following exercises are commonly prescribed to patients with a femoral
neck fracture following confirmation that the fracture has healed or that pain
free mobilization can commence as directed by the surgeon. You should
discuss the suitability of these exercises with your physiotherapist prior to
beginning them. Generally, they should be performed 3 times daily and only
provided they do not cause or increase symptoms.
Hip & Knee Bend to Straighten
Slowly bend and straighten your knee by sliding your heel forwards and
backwards along the bed or floor as far as possible and comfortable without
increasing your pain (figure 2). Repeat 10 - 20 times provided there is no
increase in symptoms.

Figure 2 Hip & Knee Bend to Straighten (right leg)

Hip Abduction
Begin this exercise lying on your back (figure 3). Keeping your knee straight,
take your leg to the side as far as possible pain free, then return to the
starting position. Keep your knee cap and toes facing the ceiling throughout
the exercise. Repeat 10 - 20 times provided there is no increase in symptoms.

Figure 3 Hip Abduction (right leg)

Hip External Rotation
Begin this exercise lying on your back with your knee bent and foot flat on
the floor (figure 4). Take your knee to the side as far as possible pain free,
then return to the starting position. Repeat 10 - 20 times provided there is no
increase in symptoms.

Figure 4 Hip External Rotation (right leg)

Bridging
Begin this exercise by lying on your back in the position demonstrated (figure
5). Slowly lift your bottom pushing through your feet, until your knees, hips
and shoulders are in a straight line. Tighten your bottom muscles (gluteals)
as you do this and hold for 2 seconds. Then slowly return to the starting
position. Repeat 10 times provided there is no increase in symptoms.

Figure 5 Bridging