What is the treatment for a subcapital hip fracture?

Treatment of Subcapital Hip Fractures

The treatment of subcapital hip fractures depends critically on whether the fracture is displaced or undisplaced: undisplaced fractures should be treated with internal fixation using multiple screws or a sliding hip screw, while displaced fractures require arthroplasty—with total hip arthroplasty preferred for younger, cognitively intact patients and hemiarthroplasty for older, cognitively impaired patients. 1

Undisplaced Subcapital Fractures

• All undisplaced intracapsular fractures should be treated with internal fixation using multiple screws or a sliding hip screw, as conservative management carries a 30-50% risk of subsequent displacement 1
• For stable (nondisplaced) femoral neck fractures, hemiarthroplasty or nonsurgical care may be considered as alternatives, though internal fixation remains the current preference 1

Displaced Subcapital Fractures

The surgical approach for displaced subcapital fractures follows a patient-centered algorithm rather than a diagnosis-only approach 2:

Age and Cognitive Function Algorithm

For younger patients (typically <65-70 years):

• Perform urgent open reduction and internal fixation (ORIF) with the goal of anatomic reduction 2
• Increasingly, total hip arthroplasty is preferred for younger patients to avoid long-term arthritis complications associated with intracapsular fractures 1

For elderly patients (≥65-70 years):

• Assess cognitive function first 2
• Cognitively intact patients: Total hip arthroplasty is the best option, providing the least pain and most mobility at 1 year compared to hemiarthroplasty or internal fixation 1, 2, 3
• Cognitively impaired patients: Bipolar hemiarthroplasty or total hip arthroplasty with larger heads (32mm or 36mm) and/or constrained sockets are viable options 2

Arthroplasty Technical Considerations

• Cemented femoral stems are strongly recommended for all arthroplasty procedures, as they improve hip function and are associated with lower residual pain postoperatively 1
• For patients choosing between unipolar and bipolar hemiarthroplasty, both can be equally beneficial 1

Critical Rationale for Treatment Selection

The displaced subcapital fracture disrupts the capsular blood supply to the femoral head, leading to avascular necrosis and resulting in a painful hip with limited function if left untreated 1. This is why arthroplasty is preferred over internal fixation in displaced fractures for elderly patients—internal fixation has a 25% revision rate within the first year in this population 3.

Perioperative Management

Surgical timing:

• Surgery should be performed within 24-48 hours of admission for improved outcomes 4

Anesthesia:

• Either spinal or general anesthesia is appropriate with no preference 4
• Multimodal analgesia incorporating a preoperative nerve block is strongly recommended 1, 4

Adjunctive measures:

• Tranexamic acid should be administered to reduce blood loss and transfusion requirements 1
• Prophylactic antibiotics within one hour of skin incision 4, 5
• Thromboprophylaxis with fondaparinux or low molecular weight heparin 4, 5

Postoperative care:

• Interdisciplinary care programs should be used to decrease complications and improve outcomes 1
• Early mobilization protocols to reduce complications 4, 5
• Regular paracetamol for pain management with cautious opioid use, especially in renal dysfunction 4, 5

Common Pitfalls

• Avoid conservative management of undisplaced fractures due to the high risk (30-50%) of subsequent displacement 1
• Do not use internal fixation for displaced fractures in elderly patients as the revision rate is unacceptably high at 25% within the first year 3
• Do not use uncemented arthroplasty as cemented stems have superior outcomes 1
• Blood loss from intracapsular fractures at the time of injury is minimal due to poor vascular supply and capsular tamponade, unlike extracapsular fractures 1