What is the management of a neck of femur fracture?

Management of Neck of Femur Fractures

Surgical management is strongly recommended for most neck of femur fractures, with the specific approach determined by fracture type, patient age, and functional status to optimize outcomes and reduce mortality. 1

Classification and Initial Assessment

• Neck of femur fractures are classified as either intracapsular (subcapital, transcervical, basicervical) or extracapsular (intertrochanteric, subtrochanteric) 1
• Blood loss is typically minimal in intracapsular fractures due to poor vascular supply and capsular tamponade, while extracapsular fractures may have blood loss exceeding one liter 1
• Extracapsular fractures are generally more painful than intracapsular fractures due to greater periosteal disruption 1
• Surgery should be performed within 24-48 hours of admission for better outcomes 1

Surgical Management by Fracture Type

Intracapsular Fractures

Stable/Undisplaced Fractures (Garden 1-2)

• Options include hemiarthroplasty, internal fixation, or nonsurgical care 1
• Current preference is for internal fixation with multiple cannulated screws or sliding hip screw 1, 2
• Factors associated with non-union include high Pauwels grade (vertical orientation) and use of cannulated screws 2

Unstable/Displaced Fractures (Garden 3-4)

• Arthroplasty is strongly recommended over internal fixation 1
• For healthy, active, independent older individuals without cognitive dysfunction, total hip arthroplasty (THA) is recommended 1
• For frail patients, hemiarthroplasty is preferred due to shorter operative time and lower dislocation risk 1
• Both unipolar and bipolar hemiarthroplasty provide equally beneficial outcomes 1
• In properly selected patients, THA may offer functional benefits over hemiarthroplasty but with increased risk of complications 1, 3

Extracapsular Fractures

Intertrochanteric Fractures

• Stable intertrochanteric fractures: either sliding hip screw or cephalomedullary device is recommended 1
• Unstable intertrochanteric fractures: antegrade cephalomedullary nail is recommended 1

Subtrochanteric/Reverse Obliquity Fractures

• Cephalomedullary device is strongly recommended 1

Perioperative Considerations

Anesthesia

• Either spinal or general anesthesia is appropriate (strong recommendation) 1
• Some evidence suggests regional anesthesia may reduce postoperative confusion 1

Implant Selection

• For arthroplasty, cemented femoral stems are strongly recommended 1
• Cemented arthroplasty improves hip function and is associated with lower residual pain compared to uncemented arthroplasty 1

Surgical Approach

• Current evidence does not support superiority of one surgical approach (direct anterior, lateral, or posterior) over another 1

Postoperative Management

Pain Control

• Multimodal analgesia incorporating preoperative nerve block is strongly recommended 1

Blood Loss Management

• Tranexamic acid should be administered to reduce blood loss and blood transfusion requirements 1

Postoperative Care

• Interdisciplinary care programs should be used to decrease complications and improve outcomes 1
• Postoperative care should include appropriate pain management, antibiotic prophylaxis, correction of anemia, cognitive function assessment, pressure sore prevention, nutritional support, and early mobilization 1
• Venous thromboembolism prophylaxis is strongly recommended 1

Common Pitfalls and Caveats

• Delayed surgery (>48 hours) is associated with increased morbidity and mortality 1
• Undisplaced intracapsular fractures treated conservatively have a 30-50% risk of subsequent displacement 1
• Untreated displaced intracapsular fractures can lead to avascular necrosis of the femoral head 1
• Conservative treatment of extracapsular fractures (traction and bed rest) is associated with increased morbidity, mortality, and reduced chance of returning home 1
• In younger patients (<65 years), preservation of the native femoral head through internal fixation is often preferred when possible 4, 5