How to manage a femoral neck fracture in a 55-year-old?

Management of Femoral Neck Fracture in a 55-Year-Old

For a 55-year-old with a femoral neck fracture, surgical management should be performed within 24-48 hours of admission, with treatment choice primarily determined by fracture displacement status: displaced fractures require arthroplasty (total hip arthroplasty preferred given the patient's age and likely activity level), while stable non-displaced fractures can be treated with internal fixation, though arthroplasty remains a reasonable alternative given the substantial failure rates of fixation even in stable fractures. 1, 2

Initial Assessment and Surgical Timing

• Operate within 24-48 hours of hospital admission to optimize outcomes, with surgery performed as soon as safely possible at your facility 1, 2
• Classify the fracture as either displaced (unstable) or non-displaced (stable), as this fundamentally determines treatment approach 1, 2
• Assess the patient's functional status, activity level, and cognitive function, as these factors influence the choice between total hip arthroplasty and hemiarthroplasty 1, 2

Surgical Management Based on Fracture Pattern

For Displaced (Unstable) Femoral Neck Fractures

Arthroplasty is strongly recommended over internal fixation for all displaced fractures 1, 2

• Total hip arthroplasty (THA) is preferred for a 55-year-old patient who is likely healthy, active, and independent, as THA provides superior functional outcomes compared to hemiarthroplasty 1, 2
• The functional benefit of THA comes with increased complication risk compared to hemiarthroplasty, but this trade-off is acceptable in younger, more active elderly patients 1
• Hemiarthroplasty should be reserved for frail patients with significant comorbidities, shorter operative time requirements, or higher dislocation risk concerns 1, 2

For Non-Displaced (Stable) Femoral Neck Fractures

Internal fixation with cannulated screws is an option, but be aware of substantial failure rates 2, 3, 4

• Complication rates after internal fixation of stable fractures range from 15-17%, with nonunion (39% of failures) and osteonecrosis (32% of failures) being the most common problems 3
• Reoperation rates after screw fixation reach 15.2%, with 12.4% requiring conversion to arthroplasty 3
• Consider primary arthroplasty (hemiarthroplasty or THA) even for stable fractures in select patients, particularly those with poor bone quality, advanced age, or vertical fracture orientation (Pauwels grade 2 or 3) 5, 3, 6, 4
• If choosing internal fixation, use dynamic hip screw rather than cannulated screws for vertically oriented fractures, as cannulated screws show higher nonunion rates in Pauwels grade 2-3 fractures 4

Technical Considerations for Arthroplasty

• Use cemented femoral stems (strong recommendation), as they improve hip function, reduce residual pain, and decrease periprosthetic fracture risk compared to uncemented stems 1, 2
• Either unipolar or bipolar hemiarthroplasty can be used if hemiarthroplasty is chosen, as outcomes are equivalent 1
• Surgical approach (anterior, lateral, or posterior) does not affect outcomes, so use the approach you are most experienced with 1

Anesthesia and Perioperative Management

• Either spinal or general anesthesia is appropriate, with no superiority of one over the other 1, 2
• Administer tranexamic acid to reduce blood loss and transfusion requirements 1, 2
• Implement multimodal analgesia with preoperative nerve block for optimal pain control 1, 2
• Provide antibiotic prophylaxis at the time of surgery 1, 2

Postoperative Care

• Enroll the patient in an interdisciplinary care program to decrease complications and improve outcomes 1, 2
• Initiate venous thromboembolism prophylaxis (strong recommendation) 1, 2
• Correct postoperative anemia and monitor for complications including infection, pressure sores, and cognitive dysfunction 1, 2
• Assess and support nutritional status and renal function 1, 2
• Begin early mobilization with immediate full weight-bearing after arthroplasty 1
• Perform regular wound assessment and monitor bowel/bladder function 1, 2

Key Clinical Pitfalls

• Avoid underestimating failure rates of internal fixation: Even "stable" Garden I-II fractures have 15-17% complication rates requiring reoperation, which is higher than traditionally taught 5, 3, 4
• Do not automatically choose internal fixation for non-displaced fractures in a 55-year-old: While this patient is relatively young for a femoral neck fracture, the high failure rate of fixation and excellent outcomes with THA make arthroplasty a strong consideration even for stable fractures 3, 6
• Recognize that patients with comorbidities predisposing to avascular necrosis (such as chronic steroid use, alcohol abuse, or coagulopathies) are at particularly high risk for fixation failure and should be considered for primary arthroplasty 4