1. Femoral Neck Fractures
Yasser Alwabli
Orthopedic surgery resident

2. Epidemiology
•Elderly fractures
• 5% in age less than
50
•250,000 annually in
US
•Will triple in 2050
•Surgical treatment for
displaced fracture is
cost-effective (Parker,
1992)
Shah AK, Eissler J, Radomisli T: Algorithms for the Treatment of Femoral Neck Fractures. Clin Orthop 2002:399;28-34.

3. Osteopenia and osteoporosis
•Osteoporosis remains the most important
contributing factor to hip fractures (Stevens, 1962)
•Screening with bone densiometry is effective at
predicting fracture risk. It is currently accepted to be
cost effective to screen women older than 65 years
of age (Cummings, 2002)
Cummings SR, Bates D, Black DM: Clinical Use of Bone Densiometry. JAMA 2002:288;1889-1897

4. Anatomy
•Neck connects head with
shaft and is about 3.7 cm
long.
•Neck shaft angle 130 +/-
7 degree
•It is strengthened by
calcar femorale (bony
thickening along
• its concavity).

5. Anatomy – blood supply
1.Extracapsular arterial
ring
2. Ascending cervical
branches
3. Arteries of the
ligamentum teres

6. Classification
Pauwels (1935)
aaa

7. Classification
Garden (1961)
Garden RS, Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg Br. 1961; 43(4):647

8. Classifications
Garden (1961)
Garden RS, Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg Br. 1961; 43(4):647

9. Diagnosis
•History: mechanism of injury, weight bearing,
coexisting medical conditions, prefracture condition
•Physical examination: characteristic physical
signs, examination for associated injuries
•Imaging:
o Plain X-Rays: AP pelvis, AP hip, cross table
o CT: occult fractures
o MRI: occult fractures, avascular changes

10. Management
•Non-displaced fractures:
o Non-surgical
o Surgical:
o Decrease nonunion rate and osteonecrosis
o Most surgeons recommend multiple cannulated screws
o Alternative method is a fixed angle hip compression
screw
Bhandari M, Tornetta P III, Hanson B, Swiontkowski MF: Optimal internal fixation for femoral neck fractures:
Multiple screws or sliding hip screws? J Orthop Trauma 2009;23(6):403-407

11. Management
•Technique:
o Inverted triangle
pattern of 6.5-mm
partially threaded
cannulated screws
o At least one washer
o Fully threaded
screws is suggested
technique (Boraiah S,
2010)
Bhandari M, Tornetta P III, Hanson B, Swiontkowski MF: Optimal internal fixation for femoral neck fractures:
Multiple screws or sliding hip screws? J Orthop Trauma 2009;23(6):403-407

12. Management
•Displaced fractures:
o Increased rate of nonunion and osteonecrosis
o Options include:
o Internal fixation
o Hemiarthroplasty
o THA

13. Internal fixation
Parker MJ, Blundell C: Choice of implant for internal fixation of femoral neck fractures: Meta-analysis of 25 randomised trials
including 4,925 patients. Acta Orthop Scand 1998;69:138-143.
•Meta-analysis of 25 RCT
•4,925 patients were treated with variety of implants
•Focused on complications associated with fracture
healing
•No device was proven superior to others in terms
of nonunion or fracture displacement
•No advantage in using side plate
•No evidence for number of screws for fixation

14. Hemiarthroplasty
•Advantages over open reduction and internal
fixation:
– Faster full weight bearing.
– It eliminates nonunion, osteonecrosis, failure of
fixation risks
•Disadvantages:
– It is a more extensive procedure with greater blood
loss.
– A risk of acetabular erosion exists in active
individuals.
•Cemented vs cementless
•Unipolar and bipolar

15. THA
•Indications:
o Patients who are living independently and are actively
engaged in community activities
o Preexisting degenerative changes of the hip
o Preexisting ipsilateral acetabular metastatic disease

16. THA
Keating JF, Grant A, Masson M, Scott NW, Forbes JF: Randomized comparison of reduction and fixation, bipolar
hemiarthroplasty, and total hip arthroplasty: Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone
Joint Surg Am 2006;88(2):249-260.
•Large, multicenter RCT
•Compares internal fixation, hemiarthroplasty and
THA
•207 patients
•No differences in mortality rate
•Highest secondary surgery in fixation group
•Fixation group has worst functional outcome
•Arthroplasty is more clinically effective and cost-
effective than reduction and fixation in healthy older
patients with a displaced hip fractures

17. Complications
•Nonunion: by 12 months as groin or buttock pain,
pain on hip extension, or pain with weight bearing.
5% of nondisplaced fractures and up to 25% of
displaced fractures.
•Osteonecrosis: This may present as groin, buttock
or proximal thigh pain; it complicates up to 10% of
nondisplaced fractures and up to 27% of displaced
fractures.
•Fixation failure: related to osteoporotic bone or
technical problems (malreduction, poor implant
insertion).