Why is an intracapsular femoral neck fracture (ICNF) in young patients an emergency?

From the Guidelines

Fracture of the intracapsular femur in young patients is an emergency that requires immediate surgical intervention to prevent long-term complications such as avascular necrosis and post-traumatic arthritis. The primary concern with these fractures is the disruption of the blood supply to the femoral head, which can lead to bone death if not addressed promptly 1. The risk of avascular necrosis is particularly high in young patients due to the poor vascular supply at the fracture site and the potential for tamponade effect by the capsule. According to the management of proximal femoral fractures guidelines, untreated disruption to the capsular blood supply of the head of the femur by a displaced intracapsular fracture can lead to avascular necrosis of the bone, resulting in a painful hip of limited function 1.

Some key points to consider in the management of intracapsular femur fractures in young patients include:

• The risk of subsequent displacement in undisplaced fractures, which can be as high as 30-50% 1
• The importance of achieving anatomic reduction and stable fixation to prevent complications such as nonunion and post-traumatic arthritis
• The preference for internal fixation with multiple screws or a sliding hip screw in undisplaced fractures, and hemiarthroplasty or total hip arthroplasty in displaced fractures, especially in younger patients 1
• The potential benefits of cemented arthroplasty over uncemented arthroplasty in terms of improved hip function and reduced residual pain postoperatively 1

In terms of treatment, the standard approach involves emergency surgical fixation within 6-12 hours of injury, using techniques such as multiple cannulated screws or a dynamic hip screw to achieve anatomic reduction and stable fixation. The goal of treatment is to preserve the native hip joint and maintain long-term function, avoiding early revision surgeries and the associated risks and complications. Delayed treatment can significantly increase the risk of complications, including avascular necrosis, nonunion, and post-traumatic arthritis, which can lead to lifelong disability in these otherwise healthy, active individuals.

From the Research

Fracture ICNF Femur in Young Patients as an Emergency

• Fracture ICNF femur in young patients is considered an emergency due to the risk of fat embolism syndrome (FES), a potentially life-threatening complication 2, 3, 4, 5, 6.
• FES can occur after long bone fractures, including femur fractures, and is characterized by a triad of respiratory failure, mental status changes, and petechial rash 3.
• The risk of FES is directly related to the volume of marrow displaced and inversely related to both the time to fracture stabilization and the respiratory reserve of the patient 3.
• Early fracture stabilization may prevent fat embolism and FES, and management is supportive 2, 3, 4, 5, 6.
• The development of FES can lead to significant morbidity, including cerebral manifestations, respiratory distress, and multiple organ dysfunction 4, 5.

Clinical Implications

• Orthopaedic trauma surgeons should be aware of the risk of FES in patients with long bone fractures, particularly those with bilateral femoral fractures 3.
• An algorithm for managing bilateral femoral fractures, prioritizing early stabilization with external fixation, staged intramedullary nailing, and conversion to plate fixation if FES develops, has been proposed 3.
• Early recognition and supportive therapy are crucial in the management of FES, and bedside nurses play a key role in detecting the signs and symptoms associated with FES 6.