1. Introduction

Femoral neck fractures are high-risk injuries, particularly in elderly patients with osteoporosis. The intracapsular location of the fracture threatens the blood supply to the femoral head and significantly increases the risks of avascular necrosis (AVN) and nonunion.
Early diagnosis, rapid optimization, and appropriate operative management are critical to improving outcomes and reducing morbidity and mortality.

2. Initial Assessment in the Emergency Department

A. Clinical Presentation

• Acute hip or groin pain
• Inability to bear weight
• External rotation of the affected leg
• Shortening of the limb (may be absent in nondisplaced fractures)
• Pain with gentle log-roll test

B. Mandatory Imaging

1. AP Pelvis X-ray + Cross-table lateral view
2. MRI
   • If X-ray is negative but suspicion remains high
3. CT scan
   • For complex fractures or preoperative planning

C. Laboratory Work-up

• CBC
• Renal profile
  • PT/INR, PTT (especially in patients on warfarin or DOACs)
• ECG and chest X-ray for preoperative clearance

3. Fracture Classification (Guides Management)

A. Garden Classification

• I: Incomplete/valgus impacted
• II: Complete, nondisplaced
• III: Complete, partially displaced
• IV: Complete, fully displaced

B. Pauwels Classification (based on shear angle)

• I: < 30°
• II: 30–70°
• III: > 70° (high shear, unstable)

4. Treatment Decision Algorithm

The most important factors guiding treatment:

1. Age
2. Displacement
3. Bone quality
4. Pre-injury mobility and activity level
5. Patient frailty and comorbidities

🟦 A. Nondisplaced Fractures (Garden I–II)

1. Patients < 60 years

Recommended treatment:

✔ Internal Fixation

• Three cannulated screws (standard technique)
• DHS for basicervical fractures

2. Patients 60–65 years

✔ Internal Fixation

• Decision may be individualized based on bone quality and activity level

3. Patients > 65 years

✔ Internal Fixation remains the preferred option

• Because the femoral head blood supply is likely preserved

🟥 B. Displaced Fractures (Garden III–IV)

1. Patients < 60 years

🚨 Orthopaedic Emergency

Recommended treatment:
✔ Closed or open reduction
✔ Internal fixation (ORIF)

• Aim: Preserve the native femoral head
• Ideal timing: within 6 hours
  (Reduces risk of AVN dramatically)

2. Patients 60–70 years

Treatment depends on:

• Bone quality
• Functional demand
• Comorbidities

Two acceptable options:

1. ORIF – for active, healthy patients with good bone quality
2. Arthroplasty (Hemi or THA) – for frail patients with poor bone quality

3. Patients > 70 years

✔ Arthroplasty is the gold standard (NICE & AAOS)

A. Hemiarthroplasty

Indications:

• Low-demand patients
• No pre-existing hip arthritis
• Limited mobility prior to injury

B. Total Hip Arthroplasty (THA)

Indications:

• Independent walkers
• High functional demand
• Pre-existing hip osteoarthritis
• Cognitively intact patients

Dual mobility cup recommended to reduce dislocation risk.

5. Surgical Timing

Based on NICE, AAOS, OTA:

✔ Perform surgery within 36 hours

✔ For young patients with displacement, within 6 hours

Delays increase:

• Mortality
• Pneumonia
• DVT/PE
• Pressure ulcers
• AVN risk

6. Internal Fixation Techniques

A. Three Cannulated Screws

• Triangular inverted configuration
• Subchondral purchase of the superior screw
• Anti-rotation screw may be used

B. Dynamic Hip Screw (DHS)

• Indicated for basicervical or Pauwels II–III fractures
• Allows controlled fracture compression

C. ORIF + Capsulotomy

• Reduces intracapsular pressure
• May improve femoral head perfusion

7. Arthroplasty Protocol

A. Cemented Hemiarthroplasty

• Preferred for patients > 75 years
• Lower postoperative pain
• Better early function

B. Total Hip Replacement (THA)

• Gold standard for active elderly patients
• Recommended to use dual mobility cup
• Lower dislocation risk and better long-term outcomes

8. Postoperative Management

Mobilization

• Early weight bearing as tolerated
• Physiotherapy starting day 1

DVT Prophylaxis

• LMWH or DOACs
• Duration: 28–35 days

Pain Management

• Paracetamol + NSAIDs (unless contraindicated)
• Opioids reserved for severe acute pain

9. Complications and How to Manage Them

A. Avascular Necrosis (AVN)

• Common in displaced fractures
• May appear 6–24 months post-injury
• Treatment: THA (long-term)

B. Nonunion

• Incidence: 6% or more
• Treatment options:
  • Revision ORIF + bone graft
  • Valgus intertrochanteric osteotomy (young patients)
  • THA (elderly patients)

C. Fixation Failure

• Seen in osteoporotic bone
• Requires revision surgery

10. Practical Clinical Pearls

• Displacement is the most important treatment determinant.
• Young patients: preserve the head at all costs.
• Elderly patients: arthroplasty gives the best outcomes.
• Nondisplaced fractures → internal fixation regardless of age.
• Early surgery saves lives and reduces AVN.
• Pauwels III fractures require stronger fixation.

Femoral Neck Fracture – Clinical Management Flowchart (Text Version)

                     ┌───────────────────────────┐
                     │  Suspected Femoral Neck    │
                     │         Fracture           │
                     └──────────────┬────────────┘
                                    │
                         Perform AP Pelvis X-ray
                                    │
                                    ▼
                   ┌─────────────────────────────────┐
                   │      Is the fracture visible?    │
                   └──────────────┬───────────────────┘
                                  │
                           Yes    │      No
                                  │
                                  ▼
                        Proceed with MRI
                                  │
                                  ▼
                ┌──────────────────────────────────┐
                │   Confirmed Femoral Neck Fracture │
                └───────────────────┬──────────────┘
                                    │
                         Classify the Fracture:
                     Garden I–IV + Pauwels I–III
                                    │
                                    ▼
                 ┌────────────────────────────────────┐
                 │     Is the fracture displaced?      │
                 └───────────────┬─────────────────────┘
                                 │
                       No        │         Yes
                                 │
                                 ▼
     ┌──────────────────────────────────────────────┐
     │     NONDISPLACED (Garden I–II)               │
     └──────────────┬───────────────────────────────┘
                    │
                    ▼
         ┌────────────────────────────┐
         │  Patient Age < 60 years     │
         └───────────┬────────────────┘
                     │
                     ▼
             Internal Fixation
          (3 Cannulated Screws or DHS)
                     │
                     │
                     ▼
         ┌────────────────────────────┐
         │   Patient Age 60–65 years   │
         └───────────┬────────────────┘
                     │
                     ▼
             Internal Fixation
                     │
                     │
                     ▼
         ┌────────────────────────────┐
         │   Patient Age > 65 years    │
         └───────────┬────────────────┘
                     │
                     ▼
             Internal Fixation
        (Preserved blood supply → Fix)
                     │
                     ▼
             POST-OP PROTOCOL

(Early Mobilization + DVT Prophylaxis + PT)

─────────────────────────────────────────────────────────────────

                                 ▼
     ┌──────────────────────────────────────────────┐
     │      DISPLACED (Garden III–IV)               │
     └──────────────┬───────────────────────────────┘
                    │
                    ▼
         ┌────────────────────────────┐
         │   Patient Age < 60 years     │
         └───────────┬────────────────┘
                     │
                     ▼
       ORTHOPAEDIC EMERGENCY → < 6 HOURS
          - Closed/Open Reduction
          - ORIF (Screws or Plate)
                     │
                     ▼
             Protect Femoral Head


         ┌────────────────────────────┐
         │   Patient Age 60–70 years   │
         └───────────┬────────────────┘
                     │
                     ▼
      Is the patient active & good bone quality?
                     │
          ┌──────────┴──────────┐
          │                       │
          ▼                       ▼
   YES → ORIF           NO → Arthroplasty
                               (Hemi or THA)


         ┌────────────────────────────┐
         │   Patient Age > 70 years    │
         └───────────┬────────────────┘
                     │
                     ▼
           ARTHROPLASTY is GOLD STANDARD
      - Hemiarthroplasty → Low-demand
      - THA → Active or Pre-existing OA
      - Use Dual Mobility Cup when possible

─────────────────────────────────────────────────────────────────

                         ▼
           ┌───────────────────────────────┐
           │     Post-Operative Care        │
           └────────────────────────────────┘
                       │
                       ▼
     - Early Weight Bearing as tolerated
     - DVT Prophylaxis (28–35 days)
     - PT/OT rehabilitation
     - Monitor for AVN and Nonunion
     - Follow-up X-rays at 6–12 weeks

─────────────────────────────────────────────────────────────────

                         ▼
           ┌───────────────────────────────┐
           │       Long-Term Outcomes       │
           └────────────────────────────────┘
                       │
                       ▼
     - Nondisplaced Fx → Excellent with fixation
     - Displaced Fx in elderly → Best with THA
     - Young patients → AVN risk remains
     - Consider THA for late AVN/Nonunion