Treatment of Subcapital Femur Fracture
For elderly patients with displaced subcapital femur fractures, total hip arthroplasty is the superior treatment option, providing the best functional outcomes with less pain and greater mobility compared to internal fixation or hemiarthroplasty.
Treatment Algorithm Based on Patient Characteristics
For Non-Displaced Subcapital Fractures
- All patients, regardless of age, should undergo closed reduction and internal fixation 1
- This approach is universally recommended when the fracture remains anatomically aligned 1
For Displaced Subcapital Fractures in Elderly Patients
The treatment decision hinges on cognitive function assessment 1:
Cognitively Intact Elderly Patients
- Total hip arthroplasty is the treatment of choice 1, 2
- This approach results in significantly less pain and superior mobility at 1 year compared to hemiarthroplasty or internal fixation 2
- Total hip replacement shows the lowest revision rate and best functional outcomes, with 62% achieving excellent or good Harris hip scores at 42 months 3
- Internal fixation carries an unacceptably high 25% revision rate within the first year in elderly patients 2
Cognitively Impaired Elderly Patients
- Bipolar hemiarthroplasty is the preferred option 1
- Alternative: total hip arthroplasty with larger femoral heads (32mm or 36mm) or constrained sockets to reduce dislocation risk 1
- Standard hemiarthroplasty has an 11% dislocation rate requiring additional anesthesia 2
For Young Patients with Displaced Fractures
- Urgent open reduction and internal fixation with anatomic reduction is mandatory 1
- The goal is to preserve the native femoral head and avoid arthroplasty in this population 1
Critical Technical Considerations
Surgical Approach Matters
- Use anterolateral approach rather than posterior approach 4
- The anterolateral (McKee) approach demonstrates significantly lower mortality compared to posterior (Moore) approach 4
- Posterior approaches are associated with higher dislocation rates, particularly after fracture surgery versus elective arthroplasty 3
Postoperative Management
- Immediate full weight-bearing as tolerated should be initiated 5, 6
- Early mobilization prevents recumbency complications and reduces mortality 5
- Multimodal analgesia with preoperative nerve block optimizes pain control and facilitates early mobilization 5
Essential Comorbidity Management
Osteoporosis Evaluation (Mandatory for All Patients)
- Every patient requires systematic osteoporosis evaluation and treatment 5
- Order outpatient DEXA scan, vitamin D level, calcium level, and parathyroid hormone level 5
- All patients aged 50 years and over require systematic evaluation for subsequent fracture risk using the Fracture Liaison Service (FLS) model 5
Common Pitfalls to Avoid
- Do not use internal fixation as primary treatment in elderly patients with displaced fractures - the 40% satisfactory outcome rate and 25% revision rate make this approach inferior 4, 2
- Avoid posterior surgical approaches - they carry higher mortality and dislocation rates 4, 3
- Do not neglect osteoporosis treatment - this is a fragility fracture mandating secondary prevention 5
Evidence Quality Note
While the provided guidelines 5, 6 focus on intertrochanteric fractures rather than subcapital fractures, the research evidence consistently demonstrates that for displaced subcapital fractures in elderly patients, arthroplasty (particularly total hip replacement in cognitively intact patients) provides superior outcomes to internal fixation 1, 2, 3.