Neck of femur fracture

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"femoral neck fracture" AND management

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Fracture of the Neck of Femur (NOF Fracture / Hip Fracture)

Anatomy & Why It Matters

The femoral neck is the segment between the femoral head and the trochanters. Its relationship to the hip joint capsule is the single most important anatomical factor in management.

$Sites of proximal femoral fractures — intracapsular vs extracapsular zones$

Intracapsular fractures (subcapital, transcervical, basicervical) lie within the capsule. The blood supply to the femoral head runs in retinacular fibres closely applied to the neck; a displaced intracapsular fracture disrupts these vessels and risks avascular necrosis (AVN) of the femoral head (incidence 15–35%).

Extracapsular fractures (intertrochanteric, subtrochanteric) lie outside the capsule; the retinacular blood supply is preserved and AVN is rare.

In elderly patients, the medullary blood supply is already attenuated due to fatty marrow replacement, and the artery within the ligamentum teres is often atherosclerotic — leaving the retinacular vessels as the sole supply, which is why displaced fractures almost inevitably cause AVN in this age group. - Gray's Anatomy for Students, p. 784

Epidemiology & Risk Factors

Most common in elderly osteoporotic women (post-menopausal)
Typically low-energy falls at home; the fracture often completes itself (stress fracture → fall, not fall → fracture)
Younger patients require high-energy trauma
Associated conditions: osteoporosis, Paget disease, metastases

Clinical Presentation

Feature	Finding
Pain	Severe groin/hip pain; inability to weight-bear
Deformity	Shortened and externally rotated leg
Mechanism	Psoas major inserts on lesser trochanter → when neck is detached, pulls femur proximally and into ER; adductor spasm worsens ER
Occult fracture	May walk with groin pain aggravated by weight-bearing

Classification — Garden (Intracapsular)

Garden	Description	Displacement	AVN Risk
I	Incomplete / valgus impacted	Undisplaced	Low
II	Complete, no displacement	Undisplaced	Low
III	Complete, varus angulation	Displaced	High
IV	Completely displaced	Displaced	Highest

Clinically, undisplaced = Garden I & II (stable, preserve head); displaced = Garden III & IV (arthroplasty favoured). - Grainger & Allison's Diagnostic Radiology, p. 1162

Imaging

$Displaced subcapital fracture of the femoral neck — AP radiograph$

Plain AP pelvis + true lateral hip — first-line; ~15% of fractures missed on AP alone
Look for: break in trabecular lines, sclerotic line (impacted), varus tilt
MRI — gold standard for occult fractures; more sensitive/specific than bone scan or CT
CT — useful when MRI unavailable

Management

Intracapsular Fractures

Patient Group	Fracture Type	Preferred Treatment
Elderly (>60–65) — displaced (Garden III/IV)	Intracapsular	Hemiarthroplasty (cemented or uncemented)
Active, independently mobile elderly — displaced	Intracapsular	Total hip replacement (THR)
Young patient (<60) or undisplaced (Garden I/II)	Intracapsular	Internal fixation — dynamic hip screw (DHS) or multiple cannulated screws
Athletes with stress fracture	Intracapsular	Non-weight-bearing (walker) ± surgical fixation if tension-type

Hemiarthroplasty: Femoral head removed; femoral neck trimmed to trochanters; medullary cavity reamed; metal prosthesis inserted; head articulates with native acetabulum. Acetabulum is not replaced in straightforward cases. - Gray's Anatomy for Students, p. 784

THR vs Hemiarthroplasty: Recent evidence (2025 meta-analysis, PMID 41303766) confirms higher thromboembolic risk with THR vs hemiarthroplasty — a key peri-operative consideration.

Extracapsular Fractures

Intertrochanteric/subtrochanteric: internal fixation (DHS, intramedullary nail); AVN not a concern

Complications

Complication	Notes
Avascular necrosis	15–35% displaced intracapsular; even if prosthesis placed, residual native head fragments must be monitored
Non-union	Higher risk with displaced fractures treated with fixation
DVT/PE	Significant risk; prophylaxis mandatory (LMWH ± mechanical)
Infection	Prosthetic joint infection
Leg length discrepancy	Post-operative
Mortality	~30% 1-year mortality in elderly — largely driven by pre-existing comorbidities

Stress Fractures (Athletes)

Anterior groin pain, worse with weight-bearing; night pain if delayed
Compression-type (inferior medial neck) — more stable, conservative management acceptable
Tension-type (superior lateral neck) — unstable, prone to displace → surgical referral
Conservative: restricted weight-bearing × 6 weeks, serial X-rays every 1–2 weeks
Return to running only after pain-free walking ≥1 mile - Pfenninger & Fowler's Procedures for Primary Care, p. 1312

Pre-op Workup in Elderly

Full medical workup mandatory — cardiac, respiratory, renal, metabolic
Optimise for surgery urgently (aim within 36–48 h of admission)
Treat coexisting osteoporosis (bisphosphonates, calcium/Vit D post-operatively)
VTE prophylaxis

Recent Evidence (2024–2025)

PMID 39436746 (2024, Systematic Review): Supercapsular percutaneously assisted THA vs standard posterior approach for NOF fracture in elderly — comparable outcomes with minimally invasive technique
PMID 41303766 (2025, Systematic Review): THR carries higher thromboembolic risk vs hemiarthroplasty — relevant when choosing arthroplasty type
PMID 39581960 (2024, Meta-Analysis): Global AVN incidence after femoral neck fracture surgery in adolescents — highlights the high-stakes nature of preserving the head in young patients

Sources: Gray's Anatomy for Students (p. 784); Grainger & Allison's Diagnostic Radiology (p. 1162); Pfenninger & Fowler's Procedures for Primary Care (p. 1312); Rockwood & Green's Fractures in Adults, 10th ed. (2025)

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