What is the management of a fracture of the neck of the femur?

Management of Femoral Neck Fractures

Immediate Assessment and Timing

Surgery must be performed within 24-48 hours of admission to optimize outcomes and reduce mortality. 1

Fracture Classification

• Intracapsular fractures have minimal blood loss due to poor vascular supply and capsular tamponade, but are less painful 1
• Extracapsular fractures may have significant blood loss and are generally more painful due to greater periosteal disruption 1
• Displacement status is critical: displaced fractures have dramatically higher complication rates including 14.3% avascular necrosis and 9.3% nonunion rates 2

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Surgical Management Algorithm

For Intracapsular Fractures

Displaced intracapsular fractures require arthroplasty, NOT internal fixation. 1, 3

Patient Selection for Arthroplasty Type:

Healthy, active, independent elderly patients without cognitive dysfunction:

• Total hip arthroplasty (THA) is preferred for superior functional outcomes despite increased complication risk 4, 1
• THA has increased surgical time and blood loss compared to hemiarthroplasty 1

Frail patients with multiple comorbidities:

• Hemiarthroplasty (bipolar) is strongly preferred due to shorter operative time, lower dislocation risk, and acceptable functional outcomes 4, 1, 3
• Frailty indicators include CKD stage 3, previous TIA, smoking history, alcohol abuse, and high clinical frailty scores 5
• Unipolar or bipolar designs are equally beneficial 1

Non-displaced stable intracapsular fractures:

• Can be treated with percutaneous cannulated screw fixation 4
• However, hemiarthroplasty decreases reoperation rate compared to internal fixation 6

For Extracapsular Fractures

Stable intertrochanteric fractures:

• Sliding hip screw OR cephalomedullary device are both acceptable 4, 1

Unstable intertrochanteric fractures:

• Antegrade cephalomedullary nail is required 4, 1

Subtrochanteric or reverse oblique fractures:

• Cephalomedullary device is strongly recommended 4, 1

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Critical Surgical Technique Considerations

Femoral Stem Selection

Cemented femoral stems are strongly recommended for ALL elderly hip fracture patients to improve hip function, reduce residual pain, and decrease periprosthetic fracture risk. 1, 3, 5

• Uncemented stems should NOT be used in elderly hip fracture patients due to increased periprosthetic fracture risk 1

Surgical Approach

• Posterior approach with meticulous capsular repair minimizes dislocation risk 3
• Femoral neck osteotomy should be performed at the base using an oscillating saw 3
• Insert femoral stem with 5-10 degrees of anteversion 3

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Anesthesia Selection

Either spinal or general anesthesia is appropriate with no superiority of one over the other. 1, 3

• Spinal anesthesia may reduce postoperative confusion in elderly patients 1, 3

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Perioperative Management

Pain Control

Multimodal analgesia incorporating preoperative nerve block (femoral nerve block) is strongly recommended. 1, 3, 5

• Regular paracetamol throughout the perioperative period 3
• Use opioids cautiously, especially in renal dysfunction 3
• Avoid codeine due to constipation, emesis, and association with postoperative cognitive dysfunction 3

Blood Loss Management

Tranexamic acid should be administered at the start of surgery to reduce blood loss and transfusion requirements. 1, 3, 5

• Use transfusion threshold no higher than 8 g/dL in asymptomatic patients 3
• Transfuse for symptomatic anemia 3

Infection Prevention

• Antibiotic prophylaxis is essential 4, 5

Thromboprophylaxis

Venous thromboembolism prophylaxis is strongly recommended. 1, 5

• Administer fondaparinux or low molecular weight heparin 3

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Postoperative Care Protocol

Comprehensive postoperative management must include: 4

• Appropriate pain management 4
• Correction of postoperative anemia 4, 5
• Regular assessment of cognitive function 4, 5
• Assessment for pressure sores 4, 5
• Nutritional status monitoring and support 4, 5
• Assessment and regulation of bowel and bladder function 4
• Wound assessment and care 4

Mobilization

Early mobilization with weight-bearing as tolerated is essential. 1, 3, 5

• Begin physical therapy on postoperative day one if medically stable 3
• Structured physical therapy including muscle strengthening and balance training 5

Interdisciplinary Care

Interdisciplinary care programs should be utilized to decrease complications and improve outcomes. 1, 3, 5

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Secondary Fracture Prevention

Every patient aged 50 years and over with a femoral neck fracture requires systematic evaluation for osteoporosis risk. 4, 5

• Fracture Liaison Service (FLS) is the most effective organizational structure for risk evaluation and treatment initiation 4, 5
• Arrange outpatient DEXA scan and referral to bone health clinic 3
• Address secondary hyperparathyroidism by correcting vitamin D deficiency and optimizing calcium intake before anti-osteoporotic therapy 5
• Multidimensional fall prevention strategies are crucial 5
• Long-term continuation of balance training can help prevent subsequent fractures 5

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Non-Operative Management (Rare Exception)

Non-operative management is only appropriate for a highly select subgroup: minimally displaced, stable fractures in patients who can mobilize comfortably. 7

• This represents only 3.2% of all femoral neck fractures 7
• 82% of carefully selected patients can be successfully managed without operation 7
• 30-day mortality is 6.8% with 1-year mortality of 25% in this select group 7
• Patients deemed too frail for surgery have 74% 30-day mortality and 92% 1-year mortality 7

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Common Pitfalls to Avoid

• Do NOT use internal fixation for displaced fractures in elderly patients - arthroplasty provides superior outcomes 1
• Do NOT use uncemented stems in elderly osteopenic patients due to periprosthetic fracture risk 1
• Do NOT delay surgery beyond 48 hours unless medically necessary 1
• Do NOT use NSAIDs in patients with renal dysfunction 3
• Do NOT miss the diagnosis - femoral neck fractures are delayed in 19-31% of ipsilateral femur injuries 8