Femoral Neck Fracture
Classification systems
- AO/OTA alphanumeric grouping for the proximal femur
Mechanism
In elderly patients a simple fall from standing height with a torsional or direct lateral impact on the greater trochanter is enough, because of reduced bone mineral density. In young adults it takes high energy — a road traffic collision or a fall from height — with axial loading through an abducted or externally rotated limb, and is frequently part of a polytrauma picture. Stress fractures occur in runners and military recruits from repetitive loading without an acute event.
Age considerations
- Paediatric
- Rare and always high-energy. The retinacular blood supply is precarious, so avascular necrosis rates are considerably higher than in adults; urgent anatomical reduction and stable fixation with decompression of the intracapsular haematoma is the usual approach. Physeal-sparing fixation and later growth disturbance are specific concerns.
- Young adult
- Preserving the native femoral head is the priority. Anatomical reduction, urgent fixation and correction of varus and posterior tilt are emphasised. Counsel explicitly about avascular necrosis and non-union as recognised outcomes despite optimal surgery.
- Elderly
- The decision hinges on displacement, pre-injury mobility and cognition rather than chronological age alone. Undisplaced fractures are often fixed in situ; displaced fractures in the mobile independent patient typically favour arthroplasty for a single reliable operation. Early surgery, delirium prevention, anaemia and bone health management strongly influence outcome.
Management options
Cannulated screw fixation (in situ or after reduction)showhide
Indication
Undisplaced or minimally displaced intracapsular fractures, and young patients after anatomical reduction where head preservation is the goal.
Implant design notes
Partially threaded cannulated screws so that threads cross the fracture line and allow interfragmentary compression. Placed in an inverted triangle configuration with each screw resting against the cortex for buttressing; washers help in soft bone. Poorly suited to a vertical Pauwels pattern, where shear exceeds what parallel screws control.
Approach
Percutaneous lateral approach at the level of the lesser trochanter, splitting vastus lateralis fibres, on a traction table with image intensifier.
Steps overview
- Position supine on a traction table; obtain acceptable anteroposterior and lateral fluoroscopic views
- Reduce closed if displaced; accept only near-anatomical reduction, avoiding varus and posterior tilt
- Make a lateral incision and split vastus lateralis to reach the femoral cortex
- Insert the inferior guide wire first along the calcar, then the two superior wires in an inverted triangle
- Confirm wire position on both views, avoiding joint penetration
- Measure, drill, and place partially threaded screws so all threads lie beyond the fracture line
- Compress sequentially and reassess reduction; consider capsular decompression
- Check final images, close, and plan early protected mobilisation
Notes
A vertical fracture line implies shear and often warrants a fixed-angle device instead. Screws that cross the fracture with threads on both sides block compression — a classic technical error.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Hemiarthroplastyshowhide
Indication
Displaced intracapsular fracture in an elderly patient with limited community ambulation, cognitive impairment or significant comorbidity, where a single durable operation is the objective.
Implant design notes
Unipolar or bipolar head on a cemented or uncemented stem. Cemented stems reduce periprosthetic fracture risk in osteoporotic bone but demand attention to bone cement implantation syndrome. Correct head size and restoration of offset and leg length govern stability; a bipolar articulation adds an inner bearing intended to reduce acetabular wear.
Approach
Posterior approach with meticulous capsular and short external rotator repair, or a direct lateral approach that lowers dislocation risk at the cost of abductor-related limp.
Steps overview
- Lateral decubitus positioning with secure pelvic support
- Expose through the chosen interval, preserving capsule for later repair
- Perform capsulotomy, deliver and remove the femoral head, and measure it
- Make the neck cut at the planned level relative to the lesser trochanter
- Prepare the femoral canal by broaching to the planned size
- Trial for length, offset and stability through a full range of movement
- Insert the definitive stem, cemented with modern technique if chosen, and reduce
- Repair capsule and external rotators, close in layers, mobilise on day one
Notes
Dislocation, periprosthetic fracture and acetabular erosion are the recognised failure modes. Anaesthetic communication before cementing is essential.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Total hip arthroplastyshowhide
Indication
Displaced intracapsular fracture in an independent, cognitively intact patient with reasonable life expectancy, or where pre-existing acetabular arthritis is present.
Implant design notes
Acetabular shell with a bearing surface plus femoral stem; larger heads or a dual-mobility bearing are used to counter the dislocation risk that is higher after fracture than after elective arthroplasty.
Approach
Posterior or direct lateral approach as per surgeon familiarity, with attention to component orientation.
Steps overview
- Position and expose as for arthroplasty, protecting the abductor mechanism
- Remove the head, prepare the acetabulum by sequential reaming to the subchondral plate
- Seat the shell in the intended orientation and confirm rim coverage
- Prepare the femur, trial for length, offset and stability
- Insert definitive components and reduce
- Assess stability in the provocative positions for the chosen approach
- Repair soft tissues, close, and start immediate weight bearing as allowed
Notes
Better functional scores and lower reoperation than hemiarthroplasty in the well-selected active patient, offset by a higher dislocation risk and a longer procedure.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Viva pearls
- The blood supply answer earns marks: the retinacular vessels from the medial circumflex femoral artery dominate, the ligamentum teres contributes little in adults, and displacement disrupts the retinacular supply — hence avascular necrosis.
- Garden's classification is described on the anteroposterior view; in practice most surgeons work with the displaced versus undisplaced distinction because interobserver agreement is better.
- A higher Pauwels angle means more shear across the fracture, which is why a fixed-angle device is preferred over parallel screws in vertical patterns.
- In an elderly patient the operation choice is really a patient-selection question: mobility, cognition and comorbidity drive it, not age.
- A young patient with a displaced femoral neck fracture is a surgical urgency — quote urgent anatomical reduction and stable fixation, and mention capsular decompression.
- Do not forget the medical package: analgesia including a fascia iliaca block, delirium prevention, early surgery, and bone health assessment.
Sources for further reading
- Rockwood and Green's Fractures in Adults — intracapsular hip fracture chapter
- Standard operative orthopaedics textbook — hip fractures and arthroplasty for fracture
- Apley and Solomon's System of Orthopaedics and Trauma — the hip
- National hip fracture care standards and departmental protocols
My labelled images · 1
Attach your own teaching radiographs with your own labels for pattern-recognition practice. Use anonymised study images only — never anything patient-identifiable.
Subcapital NOF managed with THR
Resident-authored study summary in original wording, not reproduced from copyrighted source text.