Fracture Neck of Femur — Classification & Post-Surgical Rehabilitation

CLASSIFICATION

Anatomical Location

The transcervical region is considerably stronger than the subcapital region, and most intracapsular fractures actually occur at the subcapital level. The exact location has not been shown to independently influence management or outcome — degree of displacement is the more critical variable. — Rockwood and Green's Fractures in Adults, 10th ed.

1. Garden Classification (Most Widely Used)

"The divisions are based on the degree of displacement, which is the basis of the commonly used classification systems." — Rockwood and Green's Fractures in Adults, 10th ed., p. 2638

2. Pauwels Classification

3. OTA/AO Classification

• 31B1 — Subcapital, non-displaced
• 31B2 — Transcervical
• 31B3 — Subcapital, displaced

4. Delbet Classification (Pediatric)

Summary of Surgical Decision by Classification

POST-SURGICAL REHABILITATION

"Rehabilitation from hip fracture begins immediately following surgery... Unrestricted weight bearing and mobility are required to enable early and ongoing rehabilitation and recovery of function." — Rockwood and Green's Fractures in Adults, 10th ed., p. 2650

Immediate Postoperative Period (Day 0–2)

• Anemia: Early postoperative Hb check. Transfuse if symptomatic (hypotension, cardiac ischaemia) or Hb < 80 g/L.
• Analgesia: Regular paracetamol (dose-adjust for low body weight); low-dose opioids as needed; short-course NSAIDs (5 days) if no contraindications (e.g., renal impairment, GI bleeding). Continue nerve blocks (femoral, fascia iliaca, or PENG block) postoperatively.
• Urinary catheters: Remove on Day 1 unless there is a specific urological indication. Prolonged catheterization increases UTI risk and delays mobility.
• Intravenous lines: Remove all unnecessary lines on Day 0 or Day 1 — each line restricts mobility and is a source of infection.
• Bowel: Aperients prescribed prophylactically; opioid-induced constipation is common.
• DVT prophylaxis: Low molecular weight heparin (LMWH) started 6–12 hours postoperatively and continued for 28–35 days. Mechanical compression stockings used intraoperatively and during immobility.

• Sit the patient out of bed on Day 0 or Day 1 (day of surgery where possible).
• Pressure area care — use pressure-relieving mattress; reassess Waterlow score.
• Position of comfort: slight abduction, neutral rotation (avoid extremes of flexion >90° or adduction if posterior approach used — dislocation precautions).

Phase 1 — Early Mobilization (Day 1–7, Inpatient)

• Arthroplasty (hemiarthroplasty or THA): Full weight-bearing as tolerated with a walking frame from Day 1. Weight-bearing restrictions are harmful in elderly patients and reduce recovery of function.
• Internal fixation (cannulated screws, DHS): Weight-bearing as tolerated; most stable undisplaced fractures allow immediate WBAT, but the surgeon's intraoperative assessment guides the prescription.

"Mobilization — Universal weight bearing as tolerated with a frame or crutches should be prescribed in the postoperative instructions following surgery in the frail older patient. This approach to rehabilitation should be universal unless there is a specific and clear reason why it should not be employed." — Rockwood and Green's Fractures in Adults, 10th ed., p. 2650

• Bed mobility: rolling, bridging, heel slides
• Sitting balance and sit-to-stand transfers
• Standing with frame
• Gait re-education: walking frame → crutches → stick
• Ankle pumps (DVT prevention)
• Quadriceps setting and inner range quads
• Active-assisted hip flexion and abduction

• Functional assessment: ability to wash, dress, toilet
• Adaptive equipment: raised toilet seat, long-handled aids, grab rails
• Dislocation precautions education (if posterior approach THA)

Phase 2 — Consolidation (Week 2–6, Inpatient or Community Rehab)

• Progress from walking frame → elbow crutches → single stick (as tolerated)
• Stair climbing: step-to-gait initially; progressing to alternate step
• Hip range of motion exercises: flexion, abduction, extension
• Strengthening: hip abductors (gluteus medius), quadriceps, hip extensors (gluteus maximus)
• Static cycling and aquatic therapy (if available) from ~4–6 weeks
• Balance and proprioception training: single-leg stance, step-ups

• Geriatrician / orthogeriatric team review: medical optimization, secondary fracture prevention
• Social worker: discharge planning, home assessment
• Dietitian: nutritional support (protein, calcium, vitamin D) — malnutrition is common in this population and impairs healing and rehabilitation participation

• Protein intake ≥ 1.0–1.2 g/kg/day
• Vitamin D 800 IU/day + calcium 1000–1200 mg/day (secondary prevention)
• Oral nutritional supplements if intake poor

Phase 3 — Advanced Strengthening and Return to Function (Week 6–12)

• Progressive resistance exercises: hip abductors, extensors, quadriceps (theraband → weights)
• Functional activities: sit-to-stand, step-ups, stairs with single step
• Balance training: progress to dynamic balance (wobble board, perturbation training)
• Gait normalisation: address Trendelenburg pattern (weak gluteus medius common after direct lateral approach)
• Walking distance targets progressing weekly

Phase 4 — Long-Term Recovery and Secondary Prevention (3–12 months)

• Many patients will not regain pre-fracture function — up to 40% require long-term mobility aids; ~20–30% are institutionalised.
• Supervised group exercise programmes (e.g., OTAGO) improve balance and reduce re-fall risk.
• Pool-based hydrotherapy continues to be useful at this stage.

• DEXA scan to confirm osteoporosis
• Bisphosphonates (alendronate, zoledronic acid) or denosumab — initiate 2–4 weeks postoperatively
• Fall risk assessment and modification (home hazard removal, vision check, medication review — especially sedatives)
• Hip protectors in high-risk patients

• Avascular necrosis (AVN): MRI at 6–12 months if pain recurs after internal fixation; more common with Garden III/IV fractures
• Nonunion: X-ray at 6 and 12 weeks after fixation; suspect if pain and inability to bear weight
• Prosthesis dislocation: precautions maintained for 6–12 weeks; commonest after posterior approach
• Leg length discrepancy: shoe raise if >1.5 cm and symptomatic
• Trendelenburg gait: targeted gluteus medius strengthening; ensure superior gluteal nerve not damaged intraoperatively

Dislocation Precautions (Post-THA / Hemiarthroplasty)

• No hip flexion > 90°
• No adduction past midline
• No internal rotation

Key Principles Summary

1. Operate within 36–48 hours of admission (unless medically unfit) — delay increases mortality.
2. Arthroplasty is preferred for most displaced fractures in elderly patients.
3. Full weight-bearing as tolerated should be the default after arthroplasty — restrictions are harmful.
4. Orthogeriatric co-management reduces 30-day mortality and length of stay.
5. Multidisciplinary rehabilitation is essential — physiotherapy, occupational therapy, nursing, nutrition, social work.
6. Secondary prevention (bisphosphonates, fall prevention) is a mandatory part of care — the contralateral hip fracture rate is 2–3% per year.