Hip fractures are common injuries, especially seen in the elderly in the emergency setting. It is also seen in young patients who perform in athletics or high energy trauma. Immediate diagnosis and management are required to prevent threatening joint complications. In the United States, the economic burden of hip fractures is amongst the top 20 expensive diagnoses, with approximately 20 billion dollars spent on the management of this injury. It is estimated there will be approximately 300,000 cases of hip fractures annually in the United States by the year 2030.
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 is an essential consideration in displaced fractures as it runs along the femoral neck.
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.Risk factors for femoral neck fractures include female gender, decreased mobility, and low bone density.
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, usually tearing the ascending cervical branches that stem off the arterial ring supply formed by the circumflex arteries. This may compromise the healing ability of the fracture, inevitably causing non-union or osteonecrosis. This is most important when considering the younger population that sustains this fracture for which arthroplasty would be inappropriate. In patients treated via open reduction internal fixation, avascular necrosis is the most common complication.
In the majority of cases, the patient will have had recent trauma. In cases of dementia or cognitive impairment, the history may be scant without the report of any trauma. This is where obtaining an account from the nursing home, or health aids are crucial. Question the nurse aids of any recent falls and change in cognition the past few days. The patient will complain of pain with a decreased range of motion of the hip. In non-displaced fractures, there may be no deformity. However, displaced fractures may present with a shortened and externally rotated lower limb.
The patient history varies depending on the mechanism of injury. The following should be obtained during the history and physical examination:
The provider should perform a complete neurovascular examination of the affected extremity. The following imagining should be ordered when indicated:
Medical assessment should include basic labs (complete blood count, basal metabolic panel, and prothrombin/international normalized ratio, if applicable) as well as a chest radiograph and electrocardiogram (EKG). Elderly patients with known or suspected cardiac disease may benefit from preoperatively cardiology evaluation. Preoperative medical optimization is vital in the geriatric population.
The Garden classification:
The Garden classification is the most used system used to communicate the type of fracture. For treatment, it is often simplified into nondisplaced (Type 1 and Type 2) versus displaced (Type 3 and Type 4).
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.
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.
Young patients with femoral neck fractures will require treatment with emergent open reduction internal fixation. 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.
Non-displaced fractures are treated with typically with percutaneous cannulated screws or a sliding hip screw. However, there a higher rate of avascular necrosis (AVN) with the use of a sliding hip screw (9%) compared to cannulated screws (4%).
With displaced fractures of the femoral neck in elderly patients, the treatment depends on the patient baseline activity level and age. Less active individuals may receive a hemiarthroplasty. 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 a hemiarthroplasty.
Summary of Operative methods
Young patients (less than 60):
Patients treated with a total hip arthroplasty or hemiarthroplasty should be weight-bearing as tolerated postoperatively. They should observe hip precautions depending on the surgical approach used for the procedures. Deep venous thrombosis prophylaxis should be started during the perioperative period and continued for 4-6 weeks postoperatively. Physical therapy should begin immediately after surgery.
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. Preoperatively, patients should be educated on the limitations on hip movements they may have due to the prosthesis. In addition, emphasis should be placed on proper activities of daily living such as sitting on the toilet, climbing stairs and sitting and standing from a seated position after surgery.
Most patients with a femoral neck fracture will present to the emergency department. One should obtain the proper injury radiograph 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 from 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 before operative treatment. Especially in females, it is often painful to urinate, so the placement of a Foley catheter for comfort within the emergency department may be necessary and discontinued postoperatively with ambulation. In the orthopedic unit, it is essential 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 postoperatively are essential to help patients return to function.
|||Crist BD,Eastman J,Lee MA,Ferguson TA,Finkemeier CG, Femoral Neck Fractures in Young Patients. Instructional course lectures. 2018 Feb 15 [PubMed PMID: 31411399]|
|||Brauer CA,Coca-Perraillon M,Cutler DM,Rosen AB, Incidence and mortality of hip fractures in the United States. JAMA. 2009 Oct 14 [PubMed PMID: 19826027]|
|||Shimizu T,Miyamoto K,Masuda K,Miyata Y,Hori H,Shimizu K,Maeda M, The clinical significance of impaction at the femoral neck fracture site in the elderly. Archives of orthopaedic and trauma surgery. 2007 Sep [PubMed PMID: 17541613]|
|||Miyamoto RG,Kaplan KM,Levine BR,Egol KA,Zuckerman JD, Surgical management of hip fractures: an evidence-based review of the literature. I: femoral neck fractures. The Journal of the American Academy of Orthopaedic Surgeons. 2008 Oct [PubMed PMID: 18832603]|
|||[PubMed PMID: 26178894]|
|||Protzman RR,Burkhalter WE, Femoral-neck fractures in young adults. The Journal of bone and joint surgery. American volume. 1976 Jul [PubMed PMID: 932067]|
|||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 PMID: 16983459]|
|||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 PMID: 8093403]|
|||[PubMed PMID: 23997141]|
|||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 PMID: 10709002]|
|||[PubMed PMID: 31536264]|
|||Li M,Cole PA, Anatomical considerations in adult femoral neck fractures: how anatomy influences the treatment issues? Injury. 2015 Mar [PubMed PMID: 25549821]|
|||Dedrick DK,Mackenzie JR,Burney RE, Complications of femoral neck fracture in young adults. The Journal of trauma. 1986 Oct [PubMed PMID: 3773004]|
|||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 PMID: 29389800]|
|||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 PMID: 12954824]|
|||Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial. Lancet (London, England). 2017 Apr 15 [PubMed PMID: 28262269]|
|||Rogmark C,Leonardsson O, Hip arthroplasty for the treatment of displaced fractures of the femoral neck in elderly patients. The bone [PubMed PMID: 26920951]|
|||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 PMID: 21768626]|
|||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 PMID: 21368076]|
|||Egol KA,Koval KJ,Zuckerman JD, Functional recovery following hip fracture in the elderly. Journal of orthopaedic trauma. 1997 Nov [PubMed PMID: 9415867]|
|||Miller CW, Survival and ambulation following hip fracture. The Journal of bone and joint surgery. American volume. 1978 Oct [PubMed PMID: 701341]|
|||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 PMID: 8915913]|