Femoral Neck Fractures

Topic updated on 08/07/16 1:40pm
  • Epidemiology
    • increasingly common due to aging population
    • women > men
    • whites > blacks
    • United states has highest incidence of hip fx rates worldwide
    • most expensive fracture to treat on per-person basis
  • Mechanism
    • high energy in young patients
    • low energy falls in older patients
  • Pathophysiology
    • healing potential
      • femoral neck is intracapsular, bathed in synovial fluid
      • lacks periosteal layer
      • callus formation limited, which affects healing
  • Associated injuries
    • femoral shaft fractures
      • 6-9% associated with femoral neck fractures  
      • treat femoral neck first followed by shaft
  • Prognosis
    • mortality
      • ~25-30% at one year (higher than vertebral compression fractures) 
    • predictors of mortality
      • pre-injury mobility is the most significant determinant for post-operative survival 
      • in patients with chronic renal failure, rates of mortality at 2 years postoperatively, are close to 45%   


  • Osteology
    • normal neck shaft-angle 130 +/- 7 degrees
    • normal anteversion 10 +/- 7 degrees
  • Blood supply to femoral head  
    • major contributor is medial femoral circumflex (lateral epiphyseal artery)
    • some contribution to anterior and inferior head from lateral femoral circumflex
    • some contribution from inferior gluteal artery
    • small and insignificant supply from artery of ligamentum teres
    • displacement of femoral neck fracture will disrupt the blood supply and cause an intracapsular hematoma (effect is controversial) q q
Garden Classification
(based on AP radiographs and does not consider lateral or sagittal plane alignment)

Type I Incomplete, ie. valgus impacted  
Type II Complete fx. nondisplaced  
Type III Complete, partially displaced  
Type IV Complete, fully displaced  
Posterior roll-off and/or angulation of femoral head leads to increased reoperation rates
Simplified Garden Classification
Nondisplaced Includes Garden I and II
Displaced Includes Garden IIII and IV
Pauwels Classification
(based on vertical orientation of fracture line)

Type I < 30 deg from horizontal

Type II 30 to 50 deg from horizontal

Type III > 50 deg from horizontal (most unstable with highest risk of nonunion and AVN)

  • Symptoms
    • impacted and stress fractures
      • slight pain in the groin or pain referred along the medial side of the thigh and knee
    • displaced fractures
      • pain in the entire hip region
  • Physical exam
    • impacted and stress fractures
      • no obvious clinical deformity
      • minor discomfort with active or passive hip range of motion, muscle spasms at extremes of motion
      • pain with percussion over greater trochanter
    • displaced fractures
      • leg in external rotation and abduction, with shortening
  • Radiographs
    • recommended views
      • obtain AP pelvis and cross-table lateral, and full length femur film of ipsilateral side
      • consider obtaining dedicated imaging of uninjured hip to use as template intraop
      • traction-internal rotation AP hip is best for defining fracture type q
      • Garden classification is based on AP pelvis
  • CT
    • helpful in determining displacement and degree of comminution in some patients
  • MRI 
    • helpful to rule out occult fracture q
    • not helpful in reliably assessing viability of femoral head after fracture
  • Bone scan
    • helpful to rule out occult fracture
    • not helpful in reliably assessing viability of femoral head after fracture
  • Duplex Scanning
    • indication
      • rule out DVT if delayed presentation to hospital after hip fracture 
  • Nonoperative
    • observation alone
      • indications
        • may be considered in some patients who are non-ambulators, have minimal pain, and who are at high risk for surgical intervention
  • Operative
    • ORIF
      • indications
        • displaced fractures in young or physiologically young patients
          • ORIF indicated for most pts <65 years of age
    • cannulated screw fixation 
      • indications
        • nondisplaced transcervical fx
        • Garden I and II fracture patterns in the physiologically elderly
        • displaced transcervical fx in young patient
          • considered a surgical emergency
          • achieve reduction to limit vascular insult
          • reduction must be anatomic, so open if necessary
    • sliding hip screw or cephalomedullary nail
      • indications
        • basicervical fracture
        • vertical fracture pattern in a young patient
          • biomechanically superior to cannulated screws
      • consider placement of additional cannulated screw above sliding hip screw to prevent rotation
    • hemiarthroplasty 
      • indications
        • controversial
        • debilitated elderly patients
        • metabolic bone disease
    • total hip arthoplasty q q    
      • indications
        • controversial
        • older active patients
        • patients with preexisting hip osteoarthritis
          • more predictable pain relief and better functional outcome than hemiarthroplasty
        • arthroplasty for Garden III and IV in patient < 85 years
  • General Surgical Consideration
    • time to surgery
      • controversial
        • reduction method and quality has more pronounced effect on healing than surgical timing
      • elderly patients with hip fractures should be brought to surgery as soon as medically optimal 
        • the benefits of early mobilization cannot be overemphasized
          • improved outcomes in medically fit patients if surgically treated less than 4 days from injury 
    • treatment approach based on
      • degree of displacement
      • physiologic age of the patient (young is < than 50
      • ipsilateral femoral neck and shaft fractures 
        • priority goes to fixing femoral neck because anatomic reduction is necessary to avoid complications of AVN and nonunion
    • fixation with implants that allow sliding
      • permit dynamic compression at fx site during axial loading
      • can cause shortening of femoral neck
        • prominent implants
        • affects biomechanics of hip joint
        • lower physical function on SF-36
        • decreased quality of life
      • anatomic reduction with intraop compression and placement of length stable devices decrease shortening
    • open versus closed reduction 
      • worse outcomes with displacement > 5 mm (higher rate of osteonecrosis and nonunions)
      • no consensus on which reduction approach is superior
      • multiple closed reduction attempts are associated with higher risk of osteonecrosis of the femoral head
  • ORIF
    • approach
      • limited anterior Smith-Peterson 
        • 10cm skin incision made beginning just distal to AIIS
        • incise deep fascia
        • develop interval between sartorious and TFL
        • external rotation of thigh accentuates dissection plane
        • LFCN is identified and retracted medially with sartorius
        • identify tendinous portion of rectus femoris, elevate off hip capsule
        • open capsule to identify femoral neck
      • Watson-Jones
        • used to gain improved exposure of lower femoral neck fractures
        • skin incision approx 2cm posterior and distal to ASIS, down toward tip of greater trochanter
        • incision curved distally and extended 10cm along anterior portion of femur
        • incise deep fascia
        • develop interval between TFL and gluteus medius
        • anterior aspect of gluteus medius and minimus is retracted posteriorly to visualize anterior hip capsule
        • capsule sharply incised with Z-shape incision
        • capsulotomy must remain anterior to lesser trochanter at all times to avoid injury to medial femoral circumflex artery
      • reduction (method may vary)
        • evacuate hematoma
        • place A to P k-wires into femoral neck/head proximal to fracture to use as joysticks for reduction
        • insert starting k-wire (for either cannulated screw or sliding hip screw) into appropriate position laterally, up to but not across the fracture
        • once reduction obtained, drive starting k-wire across fracture
        • insert second threaded tipped k-wire if adding additional fixation
  • Cannulated Screw Fixation
    • technique
      • three screws if noncomminuted (3 screw inverted triangle shown to be superior to two screws)
      • order of screw placement (this varies)
        • 1-inferior screw along calcar
        • 2-posterior/superior screw
        • 3-anterior/superior screw
      • obtain as much screw spread as possible in femoral neck
      • inverted triangle along the calcar (not central in the neck) has stronger fixation and higher load to failure 
      • four screws considered for posterior comminution
        • clear advantage of additional screws not proven in literature
      • starting point at or above level of lesser trochanter to avoid fracture
      • avoid multiple cortical perforations during guide pin or screw placement to avoid development of lateral stress riser
  • Hemiarthroplasty
    • approach
      • posterior approach has increased risk of dislocations
      • anterolateral approach has increased abductor weakness
    • technique
      • cemented superior to uncemented
      • unipolar vs. bipolar
  • Total Hip Replacement
    • technique
      • should consider using the anterolateral approach and selective use of larger heads in the setting of a femoral neck fracture
    • advantages
      • improved functional hip scores and lower re-operation rates compared to hemiarthroplasty 
    • complications
      • higher rate of dislocation with THA (~ 10%)
        • about five times higher than hemiarthroplasty 
  • Osteonecrosis 
    • incidence of 10-45% q q
    • recent studies fail to demonstrate association between time to fracture reduction and subsequent AVN
    • increased risk with
      • increase initial displacement
        • AVN can still develop in nondisplaced injuries
      • nonanatomical reduction
    • treatment
      • major symptoms not always present when AVN develops
      • young patient
        • > 50% involvement then treat with FVFG vs THA
      • older patient
        • prosthetic replacement (hemiarthroplasty vs THA)
  • Nonunion
    • incidence of 5 to 30%
      • increased incidence in displaced fractures
      • no correlation between age, gender, and rate of nonunion
    • varus malreduction most closely correlates with failure of fixation after reduction and cannulated screw fixation. 
    • treatment
      • valgus intertrochanteric osteotomy   
        • indicated in patients after femoral neck nonunion
          • can be done even in presence of AVN, as long as not severely collapsed
          • turns vertical fx line into horizontal fx line and decreases shear forces across fx line q
      • free vascularized fibula graft (FVFG)
        • indicated in young patients with a nonviable femoral head 
      • arthroplasty
        • indicated in older patients or when the femoral head is not viable
        • also an option in younger patient with a nonviable femoral head as opposed to FVFG
      • revision ORIF
  • Dislocation
    • higher rate of dislocation with THA (~ 10%)
      • about seven times higher than hemiarthroplasty


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Qbank (33 Questions)

(SBQ12.1) A 65-year-old patient sustains the injury shown in Figure A. His medical history is significant for hypertension, Type 2 diabetes and dialysis dependent chronic kidney failure. A postoperative radiograph is shown in Figure B. Based on his risk factors, what is his most likely post operative mortality at two years after surgery?
Topic Review Topic
FIGURES: A   B        

1. 13%
2. 25%
3. 45%
4. 60%
5. 100%

(OBQ13.123) A 65-year-old female sustained the injury seen in Figure A after a slip and fall getting out of the shower. She is an avid golfer and walks the course on most days. Her past medical history includes borderline hypertension and migraine headaches. Which treatment option has shown to have the lowest re-operation rate and best clinical outcomes scores in this patient population? Topic Review Topic
FIGURES: A          

1. Closed reduction with cannulated screw fixation
2. Open reduction with cannulated screw fixation
3. Closed reduction and short intramedullary nail fixation
4. Hemiarthroplasty
5. Total hip arthroplasty

(OBQ12.104) Which of the following injuries is anticipated to have a 20% chance of mortality and 50% chance of loss of independence at one year when sustained by an 85-year-old female? Topic Review Topic

1. Intra-articular distal humerus fracture
2. Distal radius fracture
3. Femoral neck fracture
4. Trimalleolar ankle fracture-dislocation
5. Periprosthetic distal femur fracture

(OBQ11.233) A 48-year-old active female underwent percutaneous screw fixation of a minimally displaced femoral neck fracture six months ago. There were no immediate post-operative complications, and she was progressed to full weight bearing three months after surgical fixation. Initial post-operative radiographs, and radiographs taken 3 months post-op revealed anatomic reduction of the fracture with no shortening. At her latest clinic visit she reports severe right groin pain, and difficulty ambulating. A current radiograph is shown in Figure A. What is the most appropriate surgical treatment? Topic Review Topic
FIGURES: A          

1. Hemiarthroplasty
2. In situ dynamic hip screw revision fixation
3. Core decompression and bone grafting
4. Valgus intertrochanteric osteotomy with blade fixation
5. Open reduction, bone grafting, and revision percutaneous screw fixation

(OBQ11.269) Which of the following cannulated screw configurations used in the treatment of subcapital femoral neck fractures is optimal? Topic Review Topic

1. Inverted triangle pattern with the inferior screw posterior to midline and adjacent to the calcar
2. Inverted triangle pattern with the inferior screw anterior to midline and adjacent to the calcar
3. Triangle pattern with the superior screw posterior to midline and adjacent to the calcar
4. Inverted triangle pattern with the inferior screw posterior to midline and central in the femoral neck
5. Inverted triangle pattern with the inferior screw anterior to midline and central in the femoral neck

(OBQ10.79) A 25-year-old man sustains the fracture seen in Figure A and is seen in pre-op holding prior to surgery. What position of his lower extremity would result in the lowest intracapsular hip pressure? Topic Review Topic
FIGURES: A          

1. Neutral rotation and flexion
2. External rotation and flexion
3. Internal rotation and extension
4. External rotation and extension
5. Internal rotation and flexion

(OBQ10.82) A 15-year-old male falls from his bicycle and lands directly on his left hip. He is unable to bear weight and presents to the emergency department with the AP pelvis radiograph seen in Figure A. Which of the following radiographic views could aid in classifying this patient's fracture pattern? Topic Review Topic
FIGURES: A          

1. Iliac oblique (Judet) view
2. Traction AP of the hip with the leg in neutral rotation
3. Outlet view of the pelvis
4. Traction AP of the hip with the leg internally rotated 15°
5. Traction AP of the hip with the leg externally rotated 15°

(OBQ09.79) A 79-year-old cyclist is involved in an accident and sustains a displaced femoral neck fracture as seen in Figure A. What is the optimal treatment? Topic Review Topic
FIGURES: A          

1. Open reduction internal fixation
2. Bipolar hemiarthroplasty
3. Unipolar hemiarthroplasty
4. Total hip arthoplasty
5. Nonoperative treatment

(OBQ09.220) A 27-year-old man sustains a displaced femoral neck fracture and undergoes urgent open reduction internal fixation. What is the most prevalent complication after this injury? Topic Review Topic

1. Flexion contracture
2. Hip instability
3. Nonunion
4. Abductor lurch
5. Osteonecrosis

(OBQ07.174) A 70-year-old woman trips on the grass while playing golf and sustains a displaced comminuted femoral neck fracture. What is the optimal treatment for this patient? Topic Review Topic

1. Open reduction internal fixation
2. Bipolar hemiarthroplasty
3. Total hip arthroplasty
4. Unipolar hemiarthroplasty
5. Traction and non operative treatment

(OBQ07.227) A 65-year-old male falls from a standing height and sustains the injury seen in Figure A and undergoes the treatment seen in Figure B. Compared to a total hip arthroplasty, this treatment is associated with which of the following: Topic Review Topic
FIGURES: A   B        

1. Increased blood loss
2. Lower incidence of revision surgery
3. Increased risk of peri-prosthetic fracture
4. Lower dislocation risk
5. Increased risk deep venous thrombosis

(OBQ06.170) A 75-year-old ambulatory male who lives independently presents with the fracture shown in Figure A. Which of the following is true regarding timing of surgical fixation and post-operative mortality? Topic Review Topic
FIGURES: A          

1. 30 day mortality is decreased if surgery is delayed 4-7 days
2. 1 year mortality is increased if surgery is delayed greater than 4 days
3. Delay of surgery due to treatment of acute medical comorbidities has no effect on post-operative mortality rates
4. 90 day mortality rate is decreased if surgery is delayed greater than 7 days
5. Timing of surgical fixation has no statistically significant affect on post-operative mortality

(OBQ05.264) A 25-year-old male is involved in an high-speed motor vehicle collision and sustains a closed femoral shaft fracture. During further evaluation, a CT scan of the chest/abdomen/pelvis reveals a non-displaced ipsilateral femoral neck fracture. Which of the following treatment options will most likely achieve anatomic healing of the femoral neck and minimize the risk of complications? Topic Review Topic

1. Retrograde femoral nail followed by compression hip screw
2. Lag screw fixation followed by plating of the femoral shaft
3. Antegrade femoral nail followed by lag screw fixation
4. Lag screw fixation followed by retrograde femoral nail
5. Proximal femoral locking plate

(OBQ04.14) Increased hip intracapsular pressures can lead to diminished femoral head perfusion. Which of the following limb positions has been shown to create the lowest intracapsular hip pressures after a femoral neck fracture? Topic Review Topic

1. flexion and internal rotation
2. extension and external rotation
3. flexion, abduction, and external rotation
4. extension, adduction, and internal rotation
5. there are no differences in hip pressures with any position

(OBQ04.57) A 30-year-old male sustains the injury seen in Figure A after a motor vehicle collision. Which of the following is the most likely complication at 2-year follow-up? Topic Review Topic
FIGURES: A          

1. Avascular necrosis
2. Hip instability
3. Malunion
4. Chondrolysis
5. Ipsilateral medial knee degenerative changes

(OBQ04.183) Valgus intertrochanteric osteotomy with blade plate fixation is the most appropriate treatment for which of the following figures? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

(OBQ04.223) An 82-year-old female sustains a valgus-impacted subcapital femoral neck fracture and undergoes cannulated screw fixation as shown in Figure A. She returns for her first follow-up visit one week later following another fall and now complains of severe hip pain. She is unable to bear weight on the limb, and a new radiograph reveals varus displacement of her fracture. She subsequently undergoes revision fixation but during this procedure, the femoral neck fracture displaces and becomes comminuted. Which is the most appropriate next step in management? Topic Review Topic
FIGURES: A          

1. Skeletal traction
2. Revision fixation of the femoral neck fracture
3. Hardware removal and placement of a sliding hip screw device
4. Hardware removal and hip arthroplasty
5. Resection hip arthroplasty

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