What is the management for a small nondisplaced subcortical fracture of the anterior right femoral head?

Management of Small Nondisplaced Subcortical Fracture of the Anterior Right Femoral Head

Internal fixation with multiple cannulated screws or a sliding hip screw is the preferred treatment for a small nondisplaced subcortical fracture of the anterior right femoral head, as conservative treatment carries a 30-50% risk of subsequent displacement. 1

Initial Assessment and Diagnosis

• MRI without contrast is the most sensitive imaging modality (nearly 100%) for confirming the diagnosis and evaluating the extent of the fracture 1
• Standard radiographs have limited sensitivity (15-35%) for detecting small subcortical fractures 1
• CT scan has moderate sensitivity (69-87%) and may be used if MRI is contraindicated 1

Treatment Algorithm

Surgical Management (Preferred Approach)

1. Internal fixation with multiple cannulated screws or sliding hip screw

   • Provides stability and prevents displacement 1
   • Minimizes risk of avascular necrosis and post-traumatic arthritis 2
   • Preserves native hip joint and function

2. Surgical timing

   • Early fixation (within 24-48 hours) is recommended to provide effective analgesia and reduce complications 2
   • Delay should only occur for medical optimization of specific conditions (uncontrolled diabetes, acute left ventricular failure, chest infection with sepsis) 2

3. Pain management

   • Multimodal analgesia incorporating preoperative nerve blocks (femoral/fascia iliaca) 1
   • Regular paracetamol administration 2
   • Careful use of opioids, especially in patients with renal dysfunction 2
   • Avoid NSAIDs in elderly patients 1

Alternative Treatment Option

In select cases where surgery is contraindicated or in very young patients with minimal fracture, core decompression with bone void filler may be considered as a less invasive alternative 3. However, this approach has less evidence supporting its use compared to internal fixation.

Postoperative Care

• Immediate, full weight-bearing to tolerance after surgery is recommended for most patients 1
• Regular imaging to assess healing progression (follow-up radiographs at 2,6, and 12 weeks) 1
• Early mobilization to improve oxygenation and respiratory function 1
• Venous thromboembolism prophylaxis with sequential compression devices during hospitalization followed by pharmacological prophylaxis for 4 weeks postoperatively 1

Potential Complications to Monitor

• Avascular necrosis of the femoral head due to disruption of blood supply 2
• Post-traumatic arthritis 4
• Nonunion or malunion
• Heterotopic ossification 4

Special Considerations

• Patient age and functional status should influence treatment decisions 1
• For younger, active patients, preservation of the native femoral head is particularly important to maintain long-term function and avoid future revision surgeries 1
• Osteoporosis evaluation should be performed in patients aged 50+ with this fracture 1

Pitfalls to Avoid

1. Delayed treatment - Increases risk of displacement and subsequent complications
2. Inadequate fixation - Can lead to failure and need for revision surgery
3. Conservative management alone - Has high failure rate (30-50%) due to subsequent displacement 1
4. Overlooking associated injuries - Carefully evaluate for concomitant acetabular fractures or ligamentous injuries
5. Inadequate pain control - Can delay mobilization and rehabilitation

By following this evidence-based approach, patients with small nondisplaced subcortical fractures of the femoral head can achieve optimal outcomes with preservation of hip function and reduced risk of long-term complications.