What are the evaluation and treatment options for non-displaced femoral neck fractures?

From the Guidelines

Non-displaced femoral neck fractures should be treated with internal fixation, hemiarthroplasty, or nonsurgical care, considering the patient's overall health and activity level, as suggested by the American Academy of Orthopaedic Surgeons clinical practice guideline summary 1. Evaluation of non-displaced femoral neck fractures begins with a thorough history and physical examination, followed by imaging studies including:

• Plain radiographs in multiple views (AP pelvis, cross-table lateral)
• Possibly CT scans for better visualization
• MRI may be used when radiographs are negative but clinical suspicion remains high Treatment options depend on patient factors, but generally involve:
• Internal fixation with multiple cannulated screws for healthy, active patients
• Arthroplasty (either hemiarthroplasty or total hip replacement) for elderly or low-demand patients with significant comorbidities The goal of treatment is to prevent displacement and complications, such as avascular necrosis, nonunion, and fixation failure, which occur more frequently in these fractures due to the tenuous blood supply to the femoral head 1. Surgery should occur within 24-48 hours of injury to reduce complications, and postoperatively, patients typically begin protected weight-bearing with physical therapy, progressing to full weight-bearing over 6-12 weeks based on fracture healing. Regular follow-up with serial radiographs is essential to monitor healing and detect complications early, as recommended by the clinical practice guideline summary 1.

From the Research

Evaluation Options

• Non-displaced femoral neck fractures are typically evaluated using the Garden classification system, which categorizes fractures into four types based on the degree of displacement 2, 3
• The Pauwels classification system is also used to classify fractures based on the angle of the fracture line, with higher grades indicating a more vertical orientation 3

Treatment Options

• Internal fixation is a common treatment option for non-displaced femoral neck fractures, with the goal of stabilizing the fracture and promoting healing 2, 4, 5
• Locking plate systems with telescoping sliding screws have been shown to be effective in treating non-displaced and displaced femoral neck fractures, with lower rates of postoperative complications in patients under 60 years old 2
• Other fixation techniques, such as multiple cancellous lag screws and sliding hip screws, are also used to treat femoral neck fractures, but may be associated with higher complication rates 4, 5
• Arthroplasty, such as hemiarthroplasty, may be considered for older, less active patients with displaced femoral neck fractures 4
• Non-sliding fixation, such as four cannulated screws, has been shown to improve clinical outcomes for displaced femoral neck fractures compared to sliding fixation 6

Factors Influencing Treatment Outcomes

• Age is a significant factor in treatment outcomes, with patients over 60 years old being more likely to experience healing problems and implant failure 2, 3
• Fracture orientation, as classified by the Pauwels system, can also influence treatment outcomes, with more vertical fractures being more likely to result in non-union 3
• Comorbidities, such as those that predispose to avascular necrosis, can also impact treatment outcomes 3