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Femoral Neck Fracture

  • Femoral neck fracture is the most common cause of a broken hip.
  • The femoral neck is the intracapsular portion of the proximal femur between the femoral head and the lesser and greater trochanters.
  • Femoral neck fractures are most common in elderly patients, although younger patients involved in high-energy trauma also are affected.
  • In the elderly, immobilization from these injuries can lead to secondary cardiopulmonary complications, severe morbidity, and mortality.
  • Classification:
    • Stable (nondisplaced fracture): May be impacted or incomplete
    • Unstable: Complete and displaced fracture
  • The occurrence of femoral neck fractures per 100,000 person years is 27.7 in males and ~63.3 in females.
  • Rates of fracture have leveled off, perhaps secondary to the use of antiresorptive agents.
  • In the young population, more males than females sustain this injury.
  • In elderly patients, females are affected 2-3 times more often than are males.
Risk Factors
  • Osteoporosis, which is the major risk factor for femoral neck fractures in the elderly
  • Factors that increase the risk of falling, such as an unsteady gait
  • Female gender (postmenopausal)
  • Physical inactivity
  • Caucasian race
  • In patients <50 years old, femoral neck fractures often are the result of high-energy trauma with a direct force along the femoral shafts.
  • In the older population, these fractures are caused by low-energy trauma, such as a fall from a standing height.
Associated Conditions
  • Osteoporosis
  • Conditions that increase the risk of a fall:
    • Poor vision and macular degeneration
    • Urinary incontinence or frequency
    • Poor balance
    • Polypharmacy
    • Syncope
    • Use of benzodiazepams
Signs and Symptoms
  • Patients have severe pain in the groin area and, with unstable fractures, the leg is shortened.
  • The patient may be unable to ambulate.
  • Patients hold their hips slightly flexed and externally rotated.
  • Pain is worsened with attempted ROM or axial loading.
  • Patients with stable fractures will not have shortening or rotational deformity.
A history of pain in the hip before the fracture is worrisome for metastatic disease.
Physical Exam
  • Perform an examination for pain on ROM, especially internal rotation.
  • With unstable fractures, the leg often is rotated externally and shortened.
  • Examine the pelvis with direct palpation and radiography to exclude a concomitant pelvic fracture.
  • Active straight-leg raise will provoke pain.
Preoperative laboratory tests, blood type and screen, chest radiographs, and an electrocardiogram are needed at time of admission.
  • Radiography:
    • AP pelvic radiographs
    • AP and cross-table lateral radiographs of the affected hip and femur
  • MRI to diagnose occult femoral neck fractures in patients with negative radiographs
  • Dedicated hip CT is useful for patients with ipsilateral femoral shaft fractures.
Pathological Findings
Elderly patients may have comminution of the femoral neck, especially in the subcapital region.
Differential Diagnosis
  • When a fracture is not obvious on the plain films of a patient with hip pain secondary to trauma, an occult (nondisplaced) fracture should be suspected.
  • Other causes of hip pain include:
    • Pelvic fracture
    • Intertrochanteric fracture
    • Infection
    • Greater trochanter bursitis
    • Metastatic disease
General Measures
  • Stable fractures should be stabilized internally with cannulated lag screws.
  • Treatment of unstable femoral neck fractures is controversial:
    • In general, displaced fractures in young (<50 years old), active patients should be reduced by closed or open means and stabilized internally with screws.
    • Because of the high rate of osteonecrosis of the femoral head, fractures in young patients (<50 years old) are considered orthopaedic emergencies.
    • In the multiply injured patient, attention to other organ systems and concurrent care with other members of the trauma team are essential.
    • In older (physiologic age >70 years) patients, more sedentary patients, or in those with Paget disease or neurologic diseases such as Parkinson disease or hemiplegia, partial or total arthroplasty is the treatment of choice.
  • In older patients with isolated femoral neck injuries, rapid medical consultation to optimize surgical outcomes is important.
  • Delayed treatment of femoral neck fractures in elderly patients can lead to major cardiopulmonary complications.
  • Patients are at bed rest.
  • Use of traction does not give pain relief and can cause skin complications.
  • Avoid decubitus ulcers of the buttock and heels.
    • Turn the patient frequently.
    • Use heel protectors and specialized beds.
  • Avoid delirium in the elderly by:
    • Constant reorientation of the patient
    • Appropriate use of calendars and clocks
    • Avoidance of medicines that can provoke delirium (e.g., long-acting benzodiazepams)
Special Therapy
Physical Therapy
  • Begin physical therapy the day after surgery.
  • Elderly patients are allowed to bear weight as tolerated after fracture repair.
  • In younger patients, weightbearing is restricted until the fracture heals.
  • Analgesics
  • In the elderly, one should observe for a change in mental status and constipation with the use of narcotic analgesics.
  • Young patients need adequate narcotic doses to facilitate rehabilitation.
  • The patient is placed supine on a fracture table, and the fracture is visualized through a small incision or percutaneously under fluoroscopy; alternatively, a lateral approach on a radiolucent table may be used.
    • In young patients or those with stable fractures:
      • 3 screws are placed with the aid of the image intensifier.
      • Screws should be spread out in a triangular pattern.
      • Screws must be inserted deeply into the subchondral bone of the femoral head.
    • Unstable fracture patterns, in which the fracture line is closer to the trochanters (basicervical fractures):
      • A hip screw and side plate are required.
      • Precise reduction of the fracture is crucial to a good outcome.
    • 6-9% of patients with femoral shaft fractures have an ipsilateral femoral neck fracture; fixation of the femoral neck takes precedence over that of the shaft.
  • Prosthetic replacement can be done through a lateral or posterior approach with uncemented or cemented devices, depending on bone geometry and surgeon comfort.
    • In minimally active patients, hemiarthroplasty (replacing only the femoral head and neck) is performed.
    • In active patients or those with pre-existing osteoarthritis, consider total hip replacement (replacement of both the acetabulum and the femoral head and neck).
  • The mortality rate in the elderly population ranges from 4-31% at 30 days after hip fracture.
  • This rate is highest during the first 6 months and in patients with multiple medical problems or prolonged immobilization.
  • Osteonecrosis of the femoral head
  • Nonunion or malunion of bone
  • Prosthetic dislocation or loosening
  • Persistent pain
  • Infection
  • Cardiopulmonary complications
  • Postoperative delirium
  • DVT
Patient Monitoring
  • Intensive cardiovascular monitoring in multiply injured patients or in patients with multiple medical problems should be instituted during the perioperative period.
  • In patients with internally stabilized fractures, radiographs are obtained once a month until union is achieved.
  • In patients who have undergone arthroplasty, radiographs are obtained at 3 and 12 months.
820.8 Femoral neck fracture
Patient Teaching
  • Patients should be informed about the high incidence of osteonecrosis (also known as AVN) of the femoral head associated with this type of injury.
  • The risk of osteonecrosis depends on the type of injury and on the timing of diagnosis and treatment.
  • A multiply injured patient has a higher risk of osteonecrosis than does a patient with an isolated injury.
  • In the elderly:
    • Calcium, vitamin D, bisphosphonates, and physical therapy should be used to reduce osteoporosis and minimize the risk of femoral neck fracture.
    • Fall prevention should be emphasized.
    • Ambulatory aids, such as walkers or canes to increase stability, are helpful.
    • Home modification strategies, such as handrails or single level homes, should be considered.
    • Externally worn hip protectors may decrease the incidence or fracture.
Q: How likely is an elderly person to get back to the previous level of ambulation?
A: ~1/2; the other 1/2 require more aids to ambulate.
Q: What is the outcome of unstable fractures in the elderly treated with internal fixation?
A: Patients treated with internal fixation may heal their fractures and save their native hip. However, risk exists that either the fracture will not heal or AVN will develop. More patients with internal fixation require a 2nd surgery than do those with replacement.

6 comments to Femoral Neck Fracture

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  • Ray Valero

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  • Yesenia Huppe

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  • Florencio Pirman

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  • Stanford Stoecklin

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