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Femoral Neck Fractures

Authors
Jillian Kazley1 ; Kaus hik Bagc hi2.

Affiliations
1 Albany Medic al Ce nter

2 Albany Medic al Colle ge

Last Up date : M arch 13, 201 9.

Introduction

Hip fractures are common injuries. Femoral neck fractures are a specific type of intracapsular hip
fracture. The femoral neck connects the femoral shaft with the femoral head. The hip joint is the
articulation of the femoral head with the acetabulum. The junctional location makes the femoral
neck prone to fracture. The blood supply of the femoral head runs along the femoral neck and is
an essential consideration in displaced fractures and patients in the younger population.

Etiology

Femoral neck fractures are associated with low energy falls in the elderly. In younger patients
sustaining a femoral neck fracture, the cause is usually secondary to high-energy trauma such as a
substantial height or motor vehicle accidents.[1][2]Risk factors for femoral neck fractures include
female gender, decreased mobility, and low bone density.[3]

Epidemiology

There are approximately 1.6 million hip fractures annually. Seventy percent of all hip fractures
occur in women. Hip fracture risk increases exponentially with age and is more common in
Caucasian females.[2][4]

Pathophysiology

The chief source of vascular supply to the femoral head is the medial femoral circumflex artery
which runs under the quadratus femoris. Displaced fractures of the femoral neck put the blood
supply at risk. This is most important when considering the younger population that sustains this
fracture for which arthroplasty would be inappropriate.[5] In patients treated via open reduction
internal fixation, avascular necrosis is the most common complication.[6]

History and Physical

Typically, the patient will have had recent trauma, however, in cases of dementia or cognitive
impairment, there may be no history of trauma. The patient will have pain with a decreased range
of motion of the hip. In a non-displaced fracture, there may be no deformity whereas displaced
fractures can present with a shortened and externally rotated hip.

History:

Low energy trauma - the mechanism is essential, and the events around the fall should be
questioned to rule out any possible syncopal cause for fall.

High energy trauma - Follow the ATLS protocol when indicated. Assess for any non-orthopedic
injuries first and then ipsilateral injuries including femur fracture or knee injury.
Important pertinent medical history: Baseline function and activity level, baseline use of
ambulatory aids, use of blood thinners, history of cancer, history of PE/ DVTs.

Evaluation

The physician should perform a complete neurovascular exam of the affected extremity.

Imaging: radiographs-AP pelvis, AP and lateral hip, AP and lateral femur, AP and lateral knee.

CT scans - help better characterize the fracture pattern or delineate a subtle fracture line, often
included in part of a trauma assessment and can be extended to include the femoral neck.

MRI - not generally used in the acute setting but may be used to evaluate for femoral neck stress
fractures.

Medical assessment should include basic labs (CBC, BMP, and PT/INR if applicable) as well as a
chest radiograph and EKG. Elderly patients with known or suspected cardiac disease may benefit
from preoperatively cardiology evaluation. Preoperative medical optimization is vital in the
geriatric population.

There are many classifications for femoral neck fracture including the most common clinical
classifications by Garden and Pauwel which includes the following[5][7]

The Garden classification:


Type I: Incomplete fracture - valgus impacted-non displaced


Type II: Complete fracture - nondisplaced


Type III: Complete fracture - partial displaced


Type IV: Complete fracture - fully displaced


The Garden classification is the most used system used to communicate the type of fracture.
For treatment, it is often simplified into non-displaced (Type 1 and Type 2) versus displaced
(Type 3 and Type 4)

Pauwel classification:

The Pauwel classification also includes the inclination angle of the fracture line relative to the
horizontal. Higher angle and more vertical fractures exhibit greater instability due to higher shear
force. These fractures also have a higher risk of osteonecrosis postoperatively.


Type I <30 degrees


Type II 30-50 degrees


Type III >50 degrees

Treatment / Management

Non-operative:

Non-operative management for these fractures is rarely the treatment course. It is only potentially
useful for non-ambulatory, comfort care, or extremely high-risk patients.

Operative:

Young patients with femoral neck fractures will require treatment with emergent open reduction
internal fixation.[1][8] Vertically oriented fractures such a Pauwel III type fractures are more
common in the younger population and high-energy trauma patients. A sliding hip screw is
biomechanically more stable for these fracture patterns. With displaced fractures in younger
patients, the goal is to achieve anatomic reduction through emergent open-reduction internal
fixation.[8]

Non-displaced fractures are treated with typically with percutaneous cannulated screws or a
sliding hip screw. However, there a higher rate of AVN with use of sliding hip screw (9%)
compared to cannulated screws (4%).[9]

With displaced fractures of the femoral neck in elderly patients, the treatment depends on the
patient baseline activity level and their age. Displaced fractures in the elderly are the treatment
depends on activity level. Less active individuals may receive a hemiarthroplasty.[10] More active
individuals are treated with total hip arthroplasty. Total hip arthroplasty is a more resilient
procedure, but it also carries an increased risk of dislocation when compared to
hemiarthroplasty.[11][12][8]

Summary of Operative methods:

Young patients (<60):


Open-reduction internal fixation


Elderly patients:

Non-displaced


Percutaneous cannulated screws or sliding hip screw


Displaced


Hemiarthroplasty- less active patients


Total hip arthroplasty- active patients


Differential Diagnosis


Hip dislocation - Displacement of the femoral head from the acetabulum


 Intertrochanteric fracture - the fracture line is more distal and lies between the greater and
lesser trochanter


Subtrochanteric fracture - the fracture Line is within 5 cm distal to the lesser trochanter


Femur fracture - the fracture line is within the femoral diaphysis


Osteoarthritis - pain that is more chronic. Usually, patients complain of groin pain. Pain
that worsens with activity or stairs


Prognosis

After femoral neck fracture, there is a 6% in-house mortality rate. There is a 1-year mortality rate
between 20-30% with the highest risk within the first six months.[13][14] Overall with hip
fractures, 51% will resume independent ambulation while 22% will remain non-ambulatory.[15]

Complications


Avascular necrosis increased risk factor with increased initial displacement and failure to
obtain an anatomical reduction[6]


Nonunion


Dislocation increased with total hip arthroplasty treatment


Postoperative and Rehabilitation Care

Patients treated with a total hip arthroplasty or hemiarthroplasty should be weight bearing as
tolerated postoperatively.[16] They should observe hip precautions depending on the surgical
approach used for the procedures. DVT prophylaxis should be started during the perioperative
period and continued for 4-6 weeks postoperatively. Physical therapy should begin immediately
after surgery.

Deterrence and Patient Education

Patients that suffer a femoral neck fracture can benefit from preoperative evaluation and
postoperative management of their comorbidities. This multidisciplinary care team may include
orthopedics, geriatric, internal medicine, trauma surgery, anesthesia, cardiology, and any other
subspecialty that may help manage the patient’s comorbidities.

Pearls and Other Issues


Young patients with femoral neck fractures should be treated emergently for stabilization
via open reduction internal fixation after completion of imaging and ATLS protocol as
 needed. With more vertically oriented fractures such a Pauwel III, a sliding hip screw is
biomechanically stable.


Elderly patients should be seen and evaluated by medical services and optimized as
needed


Displacement and baseline activity dictate the treatment plan.


A non-displaced fracture may have surgical treatment with screws in situ.


A displaced fracture may undergo a total hip arthroplasty in active individuals or a
hemiarthroplasty in less active individuals


Enhancing Healthcare Team Outcomes

Most patients with a femoral neck fracture will present to the emergency room. One should obtain
the proper injury x-ray films and history from the patient. With the identification of a femoral
neck injury, the patient should immediately become non-weight bearing. From a triage standpoint,
the younger patients that benefit joint sparing fixation should promptly obtain a referral to
orthopedics.

For elderly patients, it is vital to identify medical comorbidities. These patients should be
medically optimized prior to operative treatment. Especially in females, it is often painful to
urinate, so placement of a Foley catheter for comfort within the emergency room may be
necessary and discontinued postoperatively with ambulation. On the orthopedic unit, it is
important to note the operative approach used because it dictates the post-operative precautions
the patient should maintain. For example, for a posterior approach, the patient typically has an
abduction pillow to sleep with at night. Posterior precautions also include not crossing the legs,
leaning forward while seated, and letting the toes point inward. These precautions help prevent
dislocation. Physical therapy and mobilization post-operatively is essential to help patients return
to function.

Questions

To access free multiple choice questions on this topic, click here.

References

1.Protzman RR, Burkhalter WE. Femoral-neck fractures in young adults. J

Bone Joint Surg Am. 1976 Jul;58(5):689-95. [PubMed: 932067]

2.Johnell O, Kanis JA. An estimate of the worldwide prevalence and

disability associated with osteoporotic fractures. Osteoporos
Int. 2006 Dec;17(12):1726-33. [PubMed: 16983459]

3.Cummings SR, Black DM, Nevitt MC, Browner W, Cauley J, Ensrud K, Genant
HK, Palermo L, Scott J, Vogt TM. Bone density at various sites for
prediction of hip fractures. The Study of Osteoporotic Fractures Research
Group. Lancet. 1993 Jan 09;341(8837):72-5. [PubMed: 8093403]

4.Koval KJ, Zuckerman JD. Hip Fractures: I. Overview and Evaluation and
Treatment of Femoral-Neck Fractures. J Am Acad Orthop Surg. 1994
May;2(3):141-149. [PubMed: 10709002]

5.Li M, Cole PA. Anatomical considerations in adult femoral neck fractures:

how anatomy influences the treatment issues? Injury. 2015
Mar;46(3):453-8. [PubMed: 25549821]

6.Dedrick DK, Mackenzie JR, Burney RE. Complications of femoral neck

fracture in young adults. J Trauma. 1986 Oct;26(10):932-7. [PubMed:
3773004]

7.Kazley JM, Banerjee S, Abousayed MM, Rosenbaum AJ. Classifications in

Brief: Garden Classification of Femoral Neck Fractures. Clin. Orthop.
Relat. Res. 2018 Feb;476(2):441-445. [PMC free article: PMC6259691]
[PubMed: 29389800]

8.Bhandari M, Devereaux PJ, Swiontkowski MF, Tornetta P, Obremskey W,

Koval KJ, Nork S, Sprague S, Schemitsch EH, Guyatt GH. Internal fixation
compared with arthroplasty for displaced fractures of the femoral neck.
A meta-analysis. J Bone Joint Surg Am. 2003
Sep;85(9):1673-81. [PubMed: 12954824]

9.Fixation using Alternative Implants for the Treatment of Hip fractures

(FAITH) Investigators. Fracture fixation in the operative management of
hip fractures (FAITH): an international, multicentre, randomised
controlled trial. Lancet. 2017 Apr 15;389(10078):1519-1527. [PMC
free article: PMC5597430] [PubMed: 28262269]

10.Rogmark C, Leonardsson O. Hip arthroplasty for the treatment of

displaced fractures of the femoral neck in elderly patients. Bone Joint
J. 2016 Mar;98-B(3):291-7. [PubMed: 26920951]

11.Avery PP, Baker RP, Walton MJ, Rooker JC, Squires B, Gargan MF,
Bannister GC. Total hip replacement and hemiarthroplasty in mobile,
independent patients with a displaced intracapsular fracture of the
femoral neck: a seven- to ten-year follow-up report of a prospective
randomised controlled trial. J Bone Joint Surg Br. 2011
Aug;93(8):1045-8. [PubMed: 21768626]

12.Hedbeck CJ, Enocson A, Lapidus G, Blomfeldt R, Törnkvist H, Ponzer S,

Tidermark J. Comparison of bipolar hemiarthroplasty with total hip
arthroplasty for displaced femoral neck fractures: a concise four-year
follow-up of a randomized trial. J Bone Joint Surg Am. 2011 Mar
02;93(5):445-50. [PubMed: 21368076]

13.Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and

mortality of hip fractures in the United States. JAMA. 2009 Oct
14;302(14):1573-9. [PMC free article: PMC4410861] [PubMed: 19826027]

14.Egol KA, Koval KJ, Zuckerman JD. Functional recovery following hip
fracture in the elderly. J Orthop Trauma. 1997
Nov;11(8):594-9. [PubMed: 9415867]

15.Miller CW. Survival and ambulation following hip fracture. J Bone

Joint Surg Am. 1978 Oct;60(7):930-4. [PubMed: 701341]

16.Koval KJ, Friend KD, Aharonoff GB, Zukerman JD. Weight bearing after
hip fracture: a prospective series of 596 geriatric hip fracture
patients. J Orthop Trauma. 1996;10(8):526-30. [PubMed: 8915913]

Figures

Femoral neck fracture. Image courtesy S Bhimji MD

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