What is the appropriate management for an elderly patient with a neglected fracture neck of femur, presenting with potential comorbidities and signs of deformity, limited mobility, and pain?

Management of Neglected Femoral Neck Fracture in Elderly Patients

For elderly patients with neglected femoral neck fractures presenting with deformity, limited mobility, and pain, arthroplasty (hemiarthroplasty or total hip arthroplasty) is the definitive treatment, with surgery performed within 24-48 hours of presentation to optimize outcomes. 1, 2

Clinical Presentation and Examination Findings

A neglected femoral neck fracture (defined as >30 days from injury) in an elderly patient typically presents with:

• Shortened and externally rotated limb - the classic deformity seen with displaced intracapsular fractures 3
• Severe pain with attempted weight-bearing or hip movement, though some patients with minimally displaced fractures may retain limited ambulation ability 4
• Groin pain radiating to the knee, with tenderness over the anterior hip capsule 1
• Limited range of motion in all planes, particularly internal rotation and flexion 3
• Possible skin changes or redness suggesting prolonged immobility, pressure effects, or inflammatory response requiring immediate evaluation 4
• Leg length discrepancy with the affected limb appearing shorter 1

Critical Initial Assessment

Upon presentation, immediately obtain:

• AP pelvis and lateral hip radiographs to confirm fracture displacement and chronicity 3, 4
• Complete blood count to assess for anemia (present in 71.77% of elderly NOF fracture patients) and infection 4, 5
• Basic metabolic panel to evaluate renal function, electrolytes, and glucose control 3, 4
• ECG and cardiac evaluation given the 55.21% prevalence of cardiovascular disease in this population 5
• Assessment for comorbidities including diabetes (57.05% prevalence), hypertension (60.12% prevalence), and cognitive dysfunction 5, 2

Surgical Management Algorithm

For Displaced/Unstable Fractures (Most Common in Neglected Cases):

Arthroplasty is strongly recommended over internal fixation for displaced femoral neck fractures in elderly patients 1, 2

Choice Between Hemiarthroplasty vs. Total Hip Arthroplasty:

• Hemiarthroplasty is preferred for:

  • Frail patients with multiple comorbidities 1
  • Patients with cognitive dysfunction or dementia 2
  • Limited pre-injury mobility 2
  • Higher surgical risk profile 2

• Total hip arthroplasty is preferred for:

  • Healthy, active, independent patients without cognitive dysfunction 1, 2
  • Pre-existing hip osteoarthritis 1, 4
  • Higher functional demands 3
  • Note: THA provides superior functional outcomes but carries increased complication risk including higher dislocation rates, increased surgical time, and greater blood loss 1, 2

Critical Technical Requirements:

• Use cemented femoral stems (strong recommendation) - improves hip function, reduces residual pain, and decreases periprosthetic fracture risk in osteoporotic elderly patients 1, 2, 4
• Uncemented stems should NOT be used due to elevated periprosthetic fracture risk 1, 2
• For hemiarthroplasty, either unipolar or bipolar designs are acceptable 1

For Stage III Neglected Fractures with Avascular Necrosis:

• Replacement arthroplasty (hemiarthroplasty or total hip arthroplasty) is the treatment of choice, as osteosynthesis results are poor in this setting 6
• Internal fixation with bone grafting achieves only limited success when AVN is established 7, 6

Perioperative Management

Anesthesia:

• Either spinal or general anesthesia is appropriate 3, 1, 4
• Regional anesthesia may reduce postoperative confusion 1

Intraoperative Measures:

• Administer tranexamic acid at surgery start to reduce blood loss and transfusion requirements 1, 2, 4
• Multimodal analgesia with preoperative nerve block for optimal pain control 1, 4

Timing:

• Surgery within 24-48 hours of admission significantly improves outcomes and reduces mortality 1, 2, 4
• Delaying surgery beyond 48 hours increases complications and mortality 2

Postoperative Management

• Immediate weight-bearing as tolerated after surgery 3, 4
• VTE prophylaxis for 4 weeks postoperatively with enoxaparin, fondaparinux, or equivalent (strong recommendation) 1, 2, 4
• Interdisciplinary care with orthogeriatric comanagement to manage multiple comorbidities and decrease complications 1, 2, 4
• Early mobilization to reduce DVT risk and improve functional recovery 2
• Structured geriatric rehabilitation to prevent functional decline 2
• Referral to Fracture Liaison Service or Bone Health Clinic for osteoporosis evaluation and secondary fracture prevention 4

Expected Outcomes and Complications

Mortality Risk:

• 4.3% at 2 weeks, 17.4% at 6 months, and 26% at one year in elderly patients 8
• Mortality is primarily age and comorbidity-related rather than procedure-related 8
• Comorbidities such as anemia, diabetes, and cardiovascular disease significantly increase mortality risk 5

Common Complications:

• Postoperative hyperglycemia (31.90%), deep vein thrombosis (18.40%), and heart failure (12.88%) are most frequent 5
• Dislocation rate of 4.3% with standard hemiarthroplasty 8
• Infection and thigh pain occur in a minority of patients 8
• Longer hospital stays, delayed surgery, and extended rehabilitation are strongly associated with multiple comorbidities 5

Functional Outcomes:

• 76.4% of surviving patients achieve excellent or good functional outcomes at one year 8
• Comorbidities, particularly anemia and diabetes, correlate with higher pain levels and reduced recovery 5

Critical Pitfalls to Avoid

• Do NOT delay surgery beyond 48 hours - this dramatically increases complications and mortality 2
• Do NOT use internal fixation for displaced fractures in elderly patients - arthroplasty provides superior outcomes 1
• Do NOT use uncemented stems - they significantly increase periprosthetic fracture risk in osteoporotic bone 1, 2
• Do NOT choose THA in demented patients with multiple comorbidities - high complication rates make hemiarthroplasty the safer choice 2
• Do NOT neglect comprehensive comorbidity management - anemia (71.77% prevalence), hypertension (60.12%), diabetes (57.05%), and cardiovascular disease (55.21%) all significantly impact outcomes and require preoperative optimization 5
• Do NOT assume inability to ambulate excludes less severe fractures - even minimally displaced fractures can present with maintained weight-bearing ability initially 4