1. Femoral neck fractures Borrowed heavily from OTA core curriculum Authors: Steven A. Olson, MD and Brian Boyer, MD Kenneth J Koval, MD

2. Anatomy Physeal closure age 16 Neck-shaft angle 130° ± 7° Anteversion
10° ± 7°
Calcar femorale
Posteromedial
dense plate of bone

3. Blood supply Lateral epiphysel artery Artery of ligamentum teres
terminal branch MFC artery
predominant blood supply to weight bearing dome of head
Artery of ligamentum teres
from obturator artery
supplies anteroinferior head
Lateral femoral circumflex a.
less contribution than MFC

4. Epidemiology 250,000 Hip fractures annually At risk populations
Expected to double by 2050
50% are femoral neck fractures
At risk populations
Elderly: poor balance & vision, osteoporosis, inactivity, medications, malnutrition
incidence doubles with each decade beyond age 50
Young: high energy trauma

5. Classification
Pauwels [1935]
Angle describes vertical shear vector

6. Classification Garden [1961] I Valgus impacted or incomplete
II Complete
Non-displaced
III Complete
Partial displacement
IV Complete
Full displacement
** Portends risk of AVN and Nonunion I II
III IV

7. Classification Functional Classification Stable Unstable
Impacted (Garden I)
Non-displaced (Garden II)
Unstable
Displaced (Garden III and IV)

8. Treatment Options Non-operative Operative very limited role ORIF
Hemiarthroplasty
Total hip replacement

9. Non-displaced fractures
ORIF standard of care
Predictable healing
Nonunion < 5%
Minimal complications
AVN < 8%
Infection < 5%
Relatively quick procedure
Minimal blood loss
Early mobilization
Unrestricted weight bearing with assistive device PRN

10. Displaced fractures ORIF versus replacement
Most important considerations
are life expectancy and activity level

11. Young adults
Closed or open reduction and internal fixation is the procedure of choice
Emergent surgery

12. ORIF: most important variable is quality of reduction

13. Approach for open reduction
Smith-Peterson
Anterior approach
Best for transcervical and subcapital fractures
Fixation is performed through a second approach

14. Approach for open reduction
Watson-Jones
Anteriolateral exposure
Best for basalar neck and IT patterns
Allows placement of implant through same incision

15. What reduction is acceptable?
Ideal reduction is Anatomic
Acceptable: < 15º valgus < 10º AP angulation
Any varus is unacceptable

16. Capsulotomy
Does no harm
Adds little time

17. Screw fixation Screw location Avoid posterior/ superior quadrant
Blood supply
Cut-out
Biomechanical advantage to inferior/ calcar screw

19. Sliding hip screw fixation
Compression Hip Screws
Sacrifices large amount of bone
May injure blood supply
Biomechanically superior in cadavers
Anti-rotation screw often needed
Increased cost and operative time
No clinical advantage over parallel screws
* May have role in high energy/ vertical shear fractures

20. Arthroplasty is the procedure of choice, usually a hemiarthroplasty
Sedentary elderly
Arthroplasty is the procedure of choice, usually a hemiarthroplasty

21. Unipolar vs. bipolar Bipolar theoretical advantages
Lower dislocation rate
Less acetabular wear/ protrusio
Less pain

22. Cochrane collaboration 2010
Hemiarthroplasty
From the trials to date there is no evidence of any difference in outcome between bipolar and unipolar prostheses

23. Cemented versus uncemented
? 1% sudden death
less pain
better function

24. Active elderly
Treatment of choice for displaced femoral neck fractures is controversial

25. ORIF vs (hemi) arthroplasty for displaced femoral neck fractures
ORIF - reduced operative time, operative blood loss, need for transfusion, and risk of deep wound infection
Arthroplasty - lower revision rate
No differences found in hospital LOS, mortality, residual pain, or regaining mobility
Cochrane review 2002

26. Recent re-evaluation for role of THR for treatment of acute femoral neck fractures in the active elderly

27. ORIF vs Bipolar vs THR Prospective randomized multicenter
Displaced FN fxs, pts > 60 years
298 pts- ORIF (118); cemented bipolar (111); cemented THR (69)
ORIF fixation failure (AVN,NU) - 37%
ORIF – 8x more likely to require revision surgery than bipolar and 5x than THR
Functional outcome highest for THR
Keating et al, JBJS 2006

28. Treatment for displaced Femoral neck fractures
Younger individuals: ORIF
Oldest old: Hemiarthroplasty
Middle range of the elderly: Controversial
Hemiarthroplasty (unipolar) for displaced femoral neck fractures in sedentary elderly years old
THR for active individuals and those with pre-existing acetabular disease
ORIF for active elderly with understanding that there is a high risk for revision surgery

29. Thank you