Femoral Neck Fractures


Article Author:
Jillian Kazley


Article Editor:
Kaushik Bagchi


Editors In Chief:
Marie Amma
Jennifer Barrow
Darcy Duncan


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
3/13/2019 6:05:45 PM

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.


  • Image 7369 Not availableImage 7369 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD

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Femoral Neck Fractures - Questions

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An 85-year-old male with a history of hypothyroidism presents after a mechanical fall. A lower extremity x-ray shows a femoral neck fracture. What is the most common, acute complication associated with a femoral neck fracture?



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A 67-year-old female complains of right hip pain after a fall from standing. Radiographs show a displaced femoral neck fracture. She is an active person participating in tennis regularly and walks without any assistive devices at home. She is treated with a total hip arthroplasty rather than a hemiarthroplasty. Which complication is the more common in patients with total hip arthroplasty?



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A 65-year-old female is status post mechanical fall with left hip pain. A radiograph shows a left femoral neck fracture. What is the expected position of the patient's leg on exam?



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A frail, 82-year-old female status post mechanical fall at her nursing home presents with right hip pain. She sustained a displaced right femoral neck fracture. What is the most appropriate treatment for her fracture?



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A 35-year-old male is status post motorcycle accident with right hip pain. Radiographs show a displaced right femoral neck. What is the is the most appropriate treatment option?



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A 35-year-old male who sustained a displaced femoral neck fracture in a car accident was treated with open reduction internal fixation. Which of the following is the most important to help prevent avascular necrosis?



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Which Pauwel type fracture has the highest rate of avascular necrosis?



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A 25-year-old man sustains a midshaft femur fracture. Which of the following is true regarding the relationship between mid-shaft femur fractures and femoral neck fractures?



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Femoral Neck Fractures - References

References

Protzman RR,Burkhalter WE, Femoral-neck fractures in young adults. The Journal of bone and joint surgery. American volume. 1976 Jul     [PubMed]
Johnell O,Kanis JA, An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2006 Dec     [PubMed]
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 (London, England). 1993 Jan 9     [PubMed]
Koval KJ,Zuckerman JD, Hip Fractures: I. Overview and Evaluation and Treatment of Femoral-Neck Fractures. The Journal of the American Academy of Orthopaedic Surgeons. 1994 May     [PubMed]
Li M,Cole PA, Anatomical considerations in adult femoral neck fractures: how anatomy influences the treatment issues? Injury. 2015 Mar     [PubMed]
Kazley JM,Banerjee S,Abousayed MM,Rosenbaum AJ, Classifications in Brief: Garden Classification of Femoral Neck Fractures. Clinical orthopaedics and related research. 2018 Feb     [PubMed]
Rogmark C,Leonardsson O, Hip arthroplasty for the treatment of displaced fractures of the femoral neck in elderly patients. The bone     [PubMed]
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. The Journal of bone and joint surgery. British volume. 2011 Aug     [PubMed]
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. The Journal of bone and joint surgery. American volume. 2011 Mar 2     [PubMed]
Bhandari M,Devereaux PJ,Swiontkowski MF,Tornetta P 3rd,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. The Journal of bone and joint surgery. American volume. 2003 Sep     [PubMed]
Brauer CA,Coca-Perraillon M,Cutler DM,Rosen AB, Incidence and mortality of hip fractures in the United States. JAMA. 2009 Oct 14     [PubMed]
Egol KA,Koval KJ,Zuckerman JD, Functional recovery following hip fracture in the elderly. Journal of orthopaedic trauma. 1997 Nov     [PubMed]
Miller CW, Survival and ambulation following hip fracture. The Journal of bone and joint surgery. American volume. 1978 Oct     [PubMed]
Dedrick DK,Mackenzie JR,Burney RE, Complications of femoral neck fracture in young adults. The Journal of trauma. 1986 Oct     [PubMed]
Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial. Lancet (London, England). 2017 Apr 15     [PubMed]
Koval KJ,Friend KD,Aharonoff GB,Zukerman JD, Weight bearing after hip fracture: a prospective series of 596 geriatric hip fracture patients. Journal of orthopaedic trauma. 1996     [PubMed]

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