Managing Femoral Neck Fractures in the Elderly: A 5-Minute Presentation Guide
Opening Statement
For unstable (displaced) femoral neck fractures in elderly patients, arthroplasty is the definitive treatment—not internal fixation—and this decision should be made immediately upon diagnosis. 1, 2, 3
Classification Framework: The First Critical Decision
Intracapsular vs. Extracapsular
- Intracapsular fractures have minimal blood loss due to poor vascular supply and capsular tamponade, whereas extracapsular fractures may cause significant hemorrhage requiring aggressive resuscitation 2
- Extracapsular fractures are generally more painful than intracapsular fractures due to greater periosteal disruption 2
Displacement Status Determines Everything
- Displaced/unstable intracapsular fractures: Arthroplasty is mandatory 1, 2, 3
- Stable intertrochanteric fractures: Either sliding hip screw or cephalomedullary device 1, 2
- Unstable intertrochanteric fractures: Antegrade cephalomedullary nail required 2
- Subtrochanteric/reverse obliquity fractures: Cephalomedullary device is the only appropriate choice 1, 2
The Arthroplasty Decision Algorithm
THA vs. Hemiarthroplasty: Patient Selection Criteria
For healthy, active, independent elderly patients without cognitive dysfunction, total hip arthroplasty provides superior functional outcomes despite increased complication risk. 1, 2, 3
Choose THA when:
- Patient is independent and ambulatory pre-injury 2, 3
- Good life expectancy (typically age 70-80 years with good functional status) 4, 5
- No significant cognitive impairment 2
- Patient accepts the trade-off: better function for slightly higher dislocation and revision risk 1, 2
Choose Hemiarthroplasty when:
- Patient is frail or has limited mobility 2
- Significant cognitive dysfunction present 2
- Limited life expectancy or multiple comorbidities 3
- Either unipolar or bipolar designs are equally beneficial—no clear superiority 1, 2, 3
Critical Technical Specifications
Cementation is Non-Negotiable
Cemented femoral stems are strongly recommended for all elderly hip fracture patients undergoing arthroplasty. 1, 2, 3
- Cemented stems improve hip function, reduce residual pain, and decrease periprosthetic fracture risk 2, 3
- Uncemented stems should never be used in elderly osteoporotic patients due to dramatically increased periprosthetic fracture risk 2, 3
Anesthesia Choice
- Either spinal or general anesthesia is appropriate 1, 2, 3
- Regional anesthesia may reduce postoperative confusion 2
Perioperative Management Essentials
Timing is Survival
Surgery must be performed within 24-48 hours of admission—delays beyond this window significantly increase mortality and complications. 2, 3
Preoperative Checklist
- Implement interdisciplinary orthogeriatric comanagement immediately upon admission 3
- Obtain chest X-ray, ECG, complete blood count, coagulation studies, renal function, and baseline cognitive assessment 3
- Administer multimodal analgesia with preoperative nerve block 1, 2, 3
- Ensure adequate fluid management 3
- Never use preoperative traction—it provides no benefit and may cause harm 3
Intraoperative Protocols
- Administer tranexamic acid at surgery start to reduce blood loss and transfusion requirements 1, 2, 3
- The direct anterior approach shows promise with fewer complications and better early functional outcomes, though traditional approaches remain acceptable 6
Postoperative Care Framework
Immediate Priorities
- Initiate VTE prophylaxis for all patients 3
- Begin early mobilization with physical therapy on postoperative day one 3
- Continue multimodal analgesia 1, 2
Long-Term Management
- Every patient ≥50 years with fragility fracture requires systematic osteoporosis evaluation and treatment 3
- Implement long-term balance training and multidimensional fall prevention programs 3
Common Pitfalls to Avoid
The Four Cardinal Errors
Using internal fixation for displaced fractures in elderly patients: Arthroplasty provides superior outcomes—this is not debatable 1, 2, 3
Choosing uncemented stems in osteoporotic bone: This dramatically increases periprosthetic fracture risk 2, 3
Delaying surgery beyond 48 hours for non-critical medical optimization: Prolonged immobility kills patients 2, 3
Operating without interdisciplinary orthogeriatric comanagement: The joint care model between geriatrician and orthopedic surgeon demonstrates shortest time to surgery, shortest hospital stay, and lowest mortality rates 3
Volume-Outcome Relationship
- Low-volume surgeons and hospitals are associated with increased mortality, prolonged length of stay, and higher complication rates including pulmonary embolism, urinary tract infections, and pneumonia 7
- High-volume surgeons (those treating more minimally displaced femoral neck fractures annually) are more likely to choose arthroplasty appropriately 8
Expected Outcomes
Realistic Expectations
- Overall one-year mortality rate: approximately 20% 4
- Of surviving patients classified as "independent" pre-injury, 68% regain independent active level 4
- Dislocation rate with arthroplasty: approximately 2%, with half requiring revision 4
- Deep infection rate: <1%, but can lead to devastating outcomes 4
- Prosthetic loosening risk after fracture arthroplasty: at least 14% within 5 years (higher than elective arthroplasty for osteoarthritis) 4