What is the management of choice for an elderly female with a non-displaced femoral neck fracture?

Management of Non-Displaced Femoral Neck Fracture in Elderly Female

For an elderly female with a non-displaced femoral neck fracture, internal fixation with cannulated screws or dynamic hip screw is the standard initial treatment, though hemiarthroplasty should be strongly considered given the 10-20% failure rate of fixation and the patient's frailty profile. 1, 2

Treatment Decision Algorithm

Primary Treatment Options

Internal fixation remains the conventional approach for non-displaced (Garden 1-2) femoral neck fractures in elderly patients, but this decision requires careful consideration of failure risk 1, 3:

• Union rate with internal fixation is approximately 90.7%, meaning roughly 1 in 10 patients will experience treatment failure 3
• Conversion to arthroplasty occurs in 10.1% of patients within 5 years, with more than half of these conversions happening in the first year 4
• Reoperation rate is 15.2% due to surgical complications, primarily nonunion (39.2% of failures) and avascular necrosis (31.9% of failures) 5

When to Choose Hemiarthroplasty Over Internal Fixation

Hemiarthroplasty should be the primary treatment in elderly patients with specific risk factors 6, 2:

• Multiple frailty indicators including chronic kidney disease stage 3, previous TIA, smoking history, and alcohol abuse 6
• Female sex (women have 1.49 times higher risk of conversion to arthroplasty after fixation) 4
• Age 70-79 years (highest conversion risk group) 4
• Vertical fracture orientation (Pauwels grade 2 or 3) which significantly increases nonunion risk 3

Advantages of Hemiarthroplasty in This Population

Hemiarthroplasty provides superior mobility outcomes compared to internal fixation 2:

• Improved mobility: 6.2 seconds faster on timed "Up & Go" test at 24 months 2
• Reduced reoperation risk: Only 5% major reoperation rate versus 20% with screw fixation (number needed to harm = 6.5) 2
• Faster recovery: Shorter hospitalization (9.8 days vs 15.1 days) and better early mobilization 7

Surgical Technique Specifications

If Internal Fixation is Selected

Dynamic hip screw is preferred over cannulated screws for non-displaced fractures, particularly those with vertical orientation 3:

• Cannulated screws show significantly higher nonunion rates in Pauwels grade 2-3 fractures (p = 0.02) 3
• Surgery must be performed within 24-48 hours of admission 1

If Hemiarthroplasty is Selected

Use cemented femoral stems exclusively in elderly patients 6, 1:

• Cemented stems improve hip function, reduce residual pain, and decrease periprosthetic fracture risk 6, 1
• Uncemented stems should never be used due to increased periprosthetic fracture risk 1
• Either unipolar or bipolar designs are equally beneficial 1

Perioperative Management Protocol

Anesthesia and Surgical Adjuncts

• Either spinal or general anesthesia is appropriate, with regional anesthesia potentially reducing postoperative confusion 1
• Multimodal analgesia with preoperative nerve block for optimal pain control 6, 1
• Tranexamic acid administration at surgery start to reduce blood loss and transfusion requirements 6, 1

Postoperative Care

Comprehensive interdisciplinary management is essential 1:

• Antibiotic prophylaxis 6
• Correction of postoperative anemia 6
• Regular cognitive function assessment 6
• Pressure sore prevention 6
• Nutritional support 6
• Venous thromboembolism prophylaxis 6, 1

Rehabilitation and Secondary Prevention

Early Mobilization

Structured physical therapy with early mobilization is critical 6:

• Muscle strengthening and balance training 6
• Multidimensional fall prevention strategies 6

Metabolic Bone Disease Management

Every patient requires systematic osteoporosis evaluation 6:

• Fracture Liaison Service (FLS) is the most effective organizational structure 6
• Address vitamin D deficiency and optimize calcium intake before anti-osteoporotic therapy 6
• Correct secondary hyperparathyroidism if present 6

Critical Pitfalls to Avoid

• Do not use cannulated screws for vertically oriented fractures (Pauwels 2-3) as this significantly increases nonunion risk 3
• Do not delay surgery beyond 48 hours as this worsens outcomes 1
• Do not use uncemented stems in elderly hip fracture patients 1
• Do not overlook comorbidities predisposing to AVN (all AVN cases in one series had predisposing comorbidities) 3