Is a left femoral neck fracture seen on X-ray likely an old fracture if the patient has no right hip pain and can sleep comfortably on their right side?

Assessment of Left Femoral Neck Fracture with Minimal Symptoms

The left femoral neck fracture seen on X-ray is almost certainly acute, not old, and requires immediate orthopedic surgical consultation and admission for operative management within 24-48 hours regardless of the patient's minimal pain or ability to sleep comfortably. 1

Why This is Likely an Acute Fracture

The absence of right-sided hip pain and ability to sleep on the right side is completely expected with a left femoral neck fracture and does not suggest the fracture is old. Key distinguishing features include:

• Patients with minimally displaced or basicervical femoral neck fractures can maintain weight-bearing ability and function initially, which explains the minimal symptoms 1
• A patient's ability to walk does not exclude the possibility of a serious fracture 1
• Old, healed fractures would show characteristic radiographic features including complete trabecular bridging, remodeling, and absence of fracture lines—features that would be clearly visible on X-ray and distinct from acute fractures 2
• The clinical presentation of minimal pain with an acute femoral neck fracture is well-documented, particularly in non-displaced or minimally displaced fractures 2

Immediate Next Steps

1. Urgent Orthopedic Consultation

Obtain immediate orthopedic surgical consultation and arrange hospital admission for operative management within 24-48 hours (moderate strength recommendation). 3, 1

2. Implement Interdisciplinary Care

Initiate orthogeriatric comanagement immediately to decrease complications and improve outcomes (strong strength recommendation). 3, 1, 4

3. Obtain Essential Laboratory Studies

• Complete blood count to assess for anemia (baseline hemoglobin important for surgical planning) 3, 1
• Basic metabolic panel to evaluate for electrolyte disturbances, renal function, and glucose control 3, 1
• ECG in all elderly patients with hip fracture 4

4. Evaluate for Surgical Optimization

Assess for common modifiable variables including malnutrition, volume status, and cardiac/pulmonary diseases to optimize the patient for surgery. 3, 1, 4

5. Consider Advanced Imaging Only If Diagnosis Uncertain

If there is genuine clinical uncertainty about whether the fracture is acute versus old (which should be evident on plain radiographs), obtain MRI to assess for bone marrow edema, which would confirm acute injury. 3, 4 However, this should not delay surgical consultation.

Surgical Treatment Planning

For Displaced Fractures

Arthroplasty is the treatment of choice for displaced femoral neck fractures in elderly patients (strong strength recommendation). 1

• Hemiarthroplasty is appropriate for most elderly patients 1
• Total hip arthroplasty may be considered if the patient is active with pre-existing hip arthritis 3, 1
• Use cemented femoral stem (strong strength recommendation) 3, 1

For Non-Displaced Fractures

Internal fixation with multiple screws or sliding compression screw construct is appropriate. 5, 6

• Fractures with vertical orientation (Pauwels grade 2 or 3) treated with cannulated screws are more likely to result in non-union 2
• Consider dynamic hip screw for higher Pauwels grades 2

Critical Pitfalls to Avoid

• Do not delay surgical consultation based on minimal symptoms—the ability to ambulate or lack of severe pain does not exclude serious femoral neck fracture requiring urgent surgery 1
• Do not assume the fracture is old without clear radiographic evidence of healing—acute femoral neck fractures can present with surprisingly minimal symptoms, especially if non-displaced 1, 2
• Do not wait for "follow-up radiographs" to confirm the diagnosis—femoral neck fractures require immediate action due to high risk of displacement, avascular necrosis (14.3% incidence), and non-union (9.3% incidence) 7
• Do not discharge the patient home without orthopedic evaluation—femoral neck fractures have an 18% reoperation rate and require specialized surgical management 7

Intraoperative Considerations

Administer tranexamic acid at the start of surgery to reduce blood loss and transfusion need (strong strength recommendation). 3, 1

Postoperative Management

• Allow immediate weight-bearing as tolerated 1, 4
• Continue VTE prophylaxis for 4 weeks postoperatively 1, 4
• Refer to Fracture Liaison Service or Bone Health Clinic for osteoporosis evaluation and secondary fracture prevention (strong strength recommendation) 1, 4