What is the treatment for a neck of femur (femoral neck) fracture?

Treatment of Femoral Neck Fractures

For femoral neck fractures, surgical intervention is strongly recommended, with the specific procedure determined by fracture stability, displacement status, and patient factors, with surgery ideally performed within 24-48 hours of admission to improve outcomes. 1

Classification and Initial Management

• Fracture assessment: Femoral neck fractures are evaluated using:
  • Garden classification (based on displacement)
  • Pauwels classification (based on fracture angle)
• Timing of surgery: Surgery should be performed within 24-48 hours of admission (moderate recommendation) 1
• Pre-operative considerations:
  • Preoperative traction should NOT be used (strong recommendation) 1
  • Either spinal or general anesthesia is appropriate (strong recommendation) 1

Surgical Treatment Algorithm

1. Stable (Non-displaced) Femoral Neck Fractures

• Internal fixation with cannulated screws is typically recommended
• Parallel screw configuration is superior to vertical or separated configurations 2
• Closed reduction and internal fixation with 3 cannulated screws is a common approach

2. Unstable (Displaced) Femoral Neck Fractures

• Arthroplasty is strongly recommended over fixation 1
  • For elderly patients:
    • Hemiarthroplasty options: Either unipolar or bipolar hemiarthroplasty can be equally beneficial (moderate recommendation) 1
    • Total hip arthroplasty (THA): May provide better function but with potentially increased complications in properly selected patients (moderate recommendation) 1
    • Femoral stem fixation: Cemented femoral stems are strongly recommended 1
  • For younger patients:
    • Closed reduction and internal fixation may be attempted first, though complication rates remain high 2

3. Intertrochanteric Fractures

• Stable intertrochanteric fractures: Either sliding hip screw or cephalomedullary device is recommended (strong recommendation) 1
• Subtrochanteric or reverse obliquity fractures: Cephalomedullary device is strongly recommended 1

Surgical Approach Considerations

• No significant difference in outcomes between direct anterior, lateral, or posterior approaches 1
• Surgical approach can be selected based on surgeon preference and experience

Postoperative Care

• Begin physical therapy on postoperative day 1
• Implement an interdisciplinary care program to improve outcomes (strong recommendation) 1
• Progress from assisted to independent ambulation based on patient ability
• Regular follow-up with radiographic evaluation to assess component position and potential complications 3

Potential Complications

• Major complications to monitor:
  • Avascular necrosis (AVN) of the femoral head (6.4-17.2% incidence) 4, 2
  • Nonunion (16-18.9% incidence) 4, 2
  • Fixation failure (12.3% incidence) 2
  • Neurovascular compromise
  • Recurrent dislocation (for arthroplasty)

Special Considerations

• Pediatric femoral neck fractures: Early surgical treatment within 24 hours is recommended, with closed reduction and internal fixation showing satisfactory outcomes in 75% of cases 5
• Elderly patients with non-displaced fractures: Internal fixation is preferred over conservative management to prevent subsequent displacement and allow immediate weight-bearing 6

Key Pitfalls to Avoid

• Delaying surgery beyond 48 hours increases complication rates
• Using non-cemented stems in elderly patients increases risk of periprosthetic fracture 1
• Improper screw configuration (vertical or separated) increases nonunion rates 2
• Attempting to improve position of markedly valgus fractures can convert stable fractures to unstable ones 6