Current Reviews in Musculoskeletal Medicine

, Volume 5, Issue 3, pp 214–221 | Cite as

Contemporary management of femoral neck fractures: the young and the old

  • David A. Forsh
  • Tania A. FergusonEmail author
Trauma (MJ Gardner, Section Editor)


The optimal management strategy for femoral neck fractures remains highly debated. The femoral neck is intracapsular and the vascular supply is fragile. Furthermore, the curvature of the proximal femur results in high mechanical stresses through the femoral neck. Poor outcomes of nonunion and avascular necrosis (AVN) are common. This chapter reviews the current evidence with respect to the treatment principles of femoral neck fractures in two distinct patient populations: “young” and “old.” Contemporary controversies including surgical timing, choice of implant, arthroplasty options, nonoperative management, capsulotomy, and associated complications will be discussed.


Femoral neck fractures Physiologically young hip fracture Old hip fracture Contemporary hip fracture treatment Trauma 



No potential conflicts of interest relevant to this article were reported.


Papers of particular interest, published recently, have been highlighted as: •  Of importance •• Of major importance

  1. 1.
    Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. Instr Course Lect. 2009;58:69–81.PubMedGoogle Scholar
  2. 2.
    Protzman RR, Burkhalter WE. Femoral-neck fractures in young adults. J Bone Joint Surg Am. 1976;58:689–95.PubMedGoogle Scholar
  3. 3.
    Pauwels F. Der Schenkelhalsbruch. Ein mechaizisches Problem. F. Enke, Stuttgart, 1935.Google Scholar
  4. 4.
    Bosch U, Schreiber T, Krettek C. Reduction and fixation of displaced intracapsular fractures of the proximal femur. Clin Orthop Relat Res. 2002;399:59–71.PubMedCrossRefGoogle Scholar
  5. 5.
    Scheck M. Intracapsular fractures of the femoral neck. Comminution of the posterior neck cortex as a cause of unstable fixation. J Bone Joint Surg Am. 1959;41:1187–200.PubMedGoogle Scholar
  6. 6.
    Holmberg S, Kale’n R, Thorngren KG. Treatment and outcome of femoral neck fractures. An analysis of 2418 patients admitted from their own homes. Clin Orthop Relat Res. 1987;218:42–52.PubMedGoogle Scholar
  7. 7.
    Conn KS, Parker MJ. Undisplaced intracapsular hip fractures: results of internal fixation in 375 patients. Clin Orthop Relat Res. 2004;421:249–54.PubMedCrossRefGoogle Scholar
  8. 8.
    Ooi LH, Wong TH, Toh CL, et al. Hip fractures in nonagenarians: a study on operative and non-operative management. Injury. 2005;36:142–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Maruenda JI, Barrios C, Gomar-Sancho F. Intracapsular hip pressure after femoral neck fracture. Clin Orthop Relat Res. 1997;340:172–80.PubMedCrossRefGoogle Scholar
  10. 10.
    Swiontkowski MF, Tepic S, Perren SM, Moor R, Ganz R, Rahn BA. Laser Doppler flowmetry for bone blood flow measurement: correlation with microsphere estimates and evaluation of the effect of intracapsular pressure on femoral head blood flow. J Orthop Res. 1986;4:362–71.PubMedCrossRefGoogle Scholar
  11. 11.
    Woodhouse CF. Dynamic influences of vascular occlusion affecting the development of avascular necrosis of the femoral head. Clin Orthop Relat Res. 1964;32:119–29.PubMedGoogle Scholar
  12. 12.
    Harper WM, Barnes MR, Gregg PJ. Femoral head blood flow in femoral neck fractures. An analysis using intra-osseous pressure measurement. J Bone Joint Surg Br. 1991;73:73–5.PubMedGoogle Scholar
  13. 13.
    Holmberg S, Dalen N. Intracapsular pressure and caput circulation in nondisplaced femoral neck fractures. Clin Orthop Relat Res. 1987;219:124–6.PubMedGoogle Scholar
  14. 14.
    Strömqvist B, Nilsson LT, Egund N, Thorngren KG, Wingstrand H. Intracapsular pressures in undisplaced fractures of the femoral neck. J Bone Joint Surg Br. 1988;70:192–4.PubMedGoogle Scholar
  15. 15.
    •• Upadhyay A, Jain P, Mishra P, et al. Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint Surg Br. 2004;86(7):1035–40. This is the only prospective randomized study which looked at closed vs open reduction and showed no difference in rates of AVN or nonunion. PubMedCrossRefGoogle Scholar
  16. 16.
    Swiontkowski MF, Winquist RA, Hansen Jr ST. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am. 1984;66:837–46.PubMedGoogle Scholar
  17. 17.
    Lee CH, Huang GS, Chao KH, Jean JL, Wu SS. Surgical treatment of displaced stress fractures of the femoral neck in military recruits: a report of 42 cases. Arch Orthop Trauma Surg. 2003;123:527–33.PubMedCrossRefGoogle Scholar
  18. 18.
    Visuri T, Vara A, Meurman KO. Displaced stress fractures of the femoral neck in young male adults: a report of twelve operative cases. J Trauma. 1988;28:1562–9.PubMedCrossRefGoogle Scholar
  19. 19.
    • Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004;86:1711–6. This retrospective study is one of the more recent ones looking at the correlation of timing to surgery and outcomes of AVN and nonunion in young patients. PubMedGoogle Scholar
  20. 20.
    Manninger J, Kazar G, Fekete G, Nagy E, Zolczer L, Frenyo S. Avoidance of avascular necrosis of the femoral head, following fractures of the femoral neck, by early reduction and internal fixation. Injury. 1985;16:437–48.PubMedCrossRefGoogle Scholar
  21. 21.
    Manninger J, Kazar G, Fekete G, Fekete K, Frenyo S, Gyarfas F, Salacz T, Varga A. Significance of urgent (within 6 h) internal fixation in the management of fractures of the neck of the femur. Injury. 1989;20:101–5.PubMedCrossRefGoogle Scholar
  22. 22.
    Jain R, Koo M, Kreder HJ, Schemitsch EH, Davey JR, Mahomed NN. Comparison of early and delayed fixation of subcapital hip fractures in patients sixty years of age or less. J Bone Joint Surg Am. 2002;84:1605–12.PubMedCrossRefGoogle Scholar
  23. 23.
    Alho A. Concurrent ipsilateral fractures of the hip and femoral shaft: a meta-analysis of 659 cases. Acta Orthop Scand. 1996;67:19–28.PubMedCrossRefGoogle Scholar
  24. 24.
    Wolinsky PR, Johnson KD. Ipsilateral femoral neck and shaft fractures. Clin Orthop Relat Res. 1995;318:81–90.PubMedGoogle Scholar
  25. 25.
    Swiontkowski MF. Ipsilateral femoral shaft and hip fractures. Orthop Clin North Am. 1987;18:73–84.PubMedGoogle Scholar
  26. 26.
    Peljovich AE, Patterson BM. Ipsilateral femoral neck and shaft fractures. J Am Acad Orthop Surg. 1998;6:106–13.PubMedGoogle Scholar
  27. 27.
    Plancher KD, Donshik JD. Femoral neck and ipsilateral neck and shaft fractures in the young adult. Orthop Clin North Am. 1997;28:447–59.PubMedCrossRefGoogle Scholar
  28. 28.
    Bennett FS, Zinar DM, Kilgus DJ. Ipsilateral hip and femoral shaft fractures. Clin Orthop Relat Res. 1993;296:168–77.PubMedGoogle Scholar
  29. 29.
    Swiontkowski MF, Hansen ST, Kellam J. Ipsilateral fractures of the femoral neck and shaft. A treatment protocol. J Bone Joint Surg Am. 1984;66:260–8.PubMedGoogle Scholar
  30. 30.
    Gerber C, Stehle J, Ganz R. The treatment of fractures of the femoral neck. Clin Orthop. 1993;292:77–86.PubMedGoogle Scholar
  31. 31.
    Robinson CM, Saran D, Annan IH. Intracapsular hip fractures: Results of management adopting a treatment protocol. Clin Orthop. 1994;302:83–91.PubMedGoogle Scholar
  32. 32.
    Damany DS, Parker MJ, Chojnowski A. Complications after intracapsular hip fractures in young adults. A meta-analysis of 18 published studies involving 564 fractures. Injury. 2005;36(1):131–41.PubMedGoogle Scholar
  33. 33.
    Butt MF, Dhar SA, Gani NU, et al. Delayed fixation of displaced femoral neck fractures in younger adults. Injury. 2008;39:238–43.PubMedCrossRefGoogle Scholar
  34. 34.
    Huang CH. Treatment of neglected femoral neck fractures in young adults. Clin Orthop Relat Res 1986:117–126.Google Scholar
  35. 35.
    Roshan A, Ram S. Early return to function in young adults with neglected femoral neck fractures. Clin Orthop Relat Res. 2006;447:152–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Szita J, Cserh’ati P, Bosch U, Manninger J, Bodzay T, Fekete K. Intracapsular femoral neck fractures: the importance of early reduction and stable osteosynthesis. Injury. 2002;33 Suppl 3:C41–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Broos PL, Vercruysse R, Fourneau I, Driesen R, Stappaerts KH. Unstable femoral neck fractures in young adults: treatment with the AO 130-degree blade plate. J Orthop Trauma. 1998;12:235–40.PubMedCrossRefGoogle Scholar
  38. 38.
    Baitner AC, Maurer SG, Hickey DG, Jazrawi LM, Kummer FJ, Jamal J, Goldman S, Koval KJ. Vertical shear fractures of the femoral neck. A biomechanical study. Clin Orthop Relat Res. 1999;367:300–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Bonnaire FA, Weber AT. Analysis of fracture gap changes, dynamic and static stability of different osteosynthetic procedures in the femoral neck. Injury. 2002;33 Suppl 3:C24–32.PubMedCrossRefGoogle Scholar
  40. 40.
    Stankewich CJ, Chapman J, Muthusamy R, Quaid G, Schemitsch E, Tencer AF, Ching RP. Relationship of mechanical factors to the strength of proximal femur fractures fixed with cancellous screws. J Orthop Trauma. 1996;10:248–57.PubMedCrossRefGoogle Scholar
  41. 41.
    Blair B, Koval KJ, Kummer F, Zuckerman JD. Basicervical fractures of the proximal femur. A biomechanical study of 3 internal fixation techniques. Clin Orthop Relat Res. 1994;306:256–63.PubMedGoogle Scholar
  42. 42.
    Oakey J, Stover M, Summers H. Does screw configuration affect subtrochanteric fracture after femoral neck fixation? Clin Orthop Relat Res. 2006;443:302–6.PubMedCrossRefGoogle Scholar
  43. 43.
    Bjørgul K, Reikerås O. Outcome of undisplaced and moderately displaced femoral neck fractures. Acta Orthop Scand. 2007;78:498–504.CrossRefGoogle Scholar
  44. 44.
    •• Lindequist S. Cortical screw support in femoral neck fractures: a radiographic analysis of 87 fractures with a new mensuration technique. Acta Orthop Scand. 1993;64(3):289–93. This study demonstrated the biomechanical strength of screw placement within 3 mm of the cortical bone of the femoral neck. It highlights the importance of well placed screws in the dense subcortical bone. PubMedCrossRefGoogle Scholar
  45. 45.
    Manninger et al. Internal Fixation of Femoral Neck Fractures, An Atlas: Ch. 5, 113–114. Biomechanical aspects of cannulated screw fixation. 2007.Google Scholar
  46. 46.
    Holmes CA, Edwards WT, Myers ER, Lewallen DG, White III AA, Hayes WC. Biomechanics of pin and screw fixation of femoral neck fractures. J Orthop Trauma. 1993;7:242–7.PubMedCrossRefGoogle Scholar
  47. 47.
    Sirkin et al. A biomechanical analysis of fixation constructs in high angle femoral neck fracture. J Orthop Trauma 14 (2): 131. OTA abstract 2008.Google Scholar
  48. 48.
    • Liporace F, Gaines R, Collinge C, et al. Results of internal fixation of Pauwels type-3 vertical femoral neck fractures. J Bone Joint Surg Am. 2008;90(8):1654–9. This paper addresses the difficulty in managing high Pauwels angle neck fractures and highlights the potential benefit of a fixed angle implant compared to cannulated screws. PubMedCrossRefGoogle Scholar
  49. 49.
    Aminian A, Gao F, Fedoriw WW, Zhang LQ, Kalainov DM, Merk BR. Vertically oriented femoral neck fractures: mechanical analysis of four fixation techniques. J Orthop Trauma. 2007;21:544–8.PubMedCrossRefGoogle Scholar
  50. 50.
    Koval KJ, Zuckerman JD. Hip Fractures. I. Overview and evaluation and treatment of femoral-neck fractures. J Am Acad Orthop Surg. 1994;2:141–9.PubMedGoogle Scholar
  51. 51.
    Cummings SR, Rubin SM, Black D. The future of hip fractures in the United States. Numbers, cost, and potential effects of post-menopausal estrogen. Clin Orthop Relat Res. 1990;252:163–6.PubMedGoogle Scholar
  52. 52.
    Papadimitropoulos EA, Coyte PC, Josse RG, et al. Current and projected rates of hip fracture in Canada. CMAJ. 1997;157(10):1357–63.PubMedGoogle Scholar
  53. 53.
    Cooper C, Campion G, Melton LJ. Hip fractures in the elderly: A worldwide projection. Osteoporos Int. 1992;2:285–9.PubMedCrossRefGoogle Scholar
  54. 54.
    Courtney AC, Wachte EF, Myers ER, Hayes WC. Effects of loading rate on strength of the proximal femur. Calcif Tissue Int. 1994;55:53–5.PubMedCrossRefGoogle Scholar
  55. 55.
    Tanaka J, Seki N, Tokimura F, et al. Conservative treatment of Garden stage I femoral neck fracture in elderly patients. Arch Orthop Trauma Surg. 2002;122:24–8.PubMedGoogle Scholar
  56. 56.
    Goldstein CB, Ferguson T, Bhandari M, et al. Implants for fixation of femoral neck fractures. Tech Orthop. 2008;23(4):301–8.CrossRefGoogle Scholar
  57. 57.
    Egol KA, Strauss EJ. Perioperative considerations in geriatric patients with hip fractures: what is the evidence? J Orthop Trauma. 2009;23(6):386–94.PubMedCrossRefGoogle Scholar
  58. 58.
    Sherk HH, Snape WJ, Loprete FL. Internal fixation versus nontreatment of hip fractures in senile patients. Clin Orthop Relat Res. 1979;280:196–8.Google Scholar
  59. 59.
    Hedstrom M. Are patients with a nonunion after a femoral neck fracture more osteoporotic than others? BMD measurement before the choice of treatment: a pilot study of hip BMD and biochemical bone markers in patients with femoral neck fractures. Acta Orthop Scand. 2004;75(1):50–2.PubMedCrossRefGoogle Scholar
  60. 60.
    •• Bhandari M, Devereaux PJ, Swiontkowski MF, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am. 2003;85(9):1673–81. This landmark meta-analysis revealed a higher reoperation/failure rate of internal fixation compared to arthroplasty. This has pushed many surgeons towards arthroplasty for fracture. PubMedGoogle Scholar
  61. 61.
    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(2):138–43.PubMedCrossRefGoogle Scholar
  62. 62.
    Zlowodzki M, Jonsson A, Paulke R, et al. Shortening after femoral neck fracture fixation: is there a solution? Clin Orthop Relat Res. 2007;461:213–8.PubMedGoogle Scholar
  63. 63.
    • Zlowodzki M, Brink O, Switzer J, et al. The effect of shortening and varus collapse of the femoral neck on function after fixation of intracapsular fracture of the hip. J Bone Joint Surg Br. 2008;90(11):1487–94. Highlights the effects of varus collapse/shortening and correlation with decreased functional outcomes and predictability of ambulatory aid usage. PubMedCrossRefGoogle Scholar
  64. 64.
    Lu-Yao GL, Keller RB, Littenberg B, et al. Outcomes after displaced fractures of the femoral neck. A meta-analysis of one hundred and six published reports. J Bone Joint Surg Am. 1994;76(1):15–25.PubMedGoogle Scholar
  65. 65.
    Ravikumar KJ, Marsh G. Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur—13 year results of a prospective randomized study. Injury. 2000;31:793–7.PubMedCrossRefGoogle Scholar
  66. 66.
    •• Blomfeldt R, Törnkvist H, Eriksson K, et al. A randomized controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients. J Bone Joint Surg Br. 2007;89(2):160–5. Study showed better outcomes in Harris Hip Scores favoring total hip arthoplasty vs. hemi. Of note, this was in patients aged 70–90 who were lucid and not cognitively impaired. PubMedCrossRefGoogle Scholar
  67. 67.
    Keating JF, Grant A, Masson M, et al. 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):249–60.PubMedCrossRefGoogle Scholar
  68. 68.
    Wathne RA, Koval KJ, Aharonoff GB, Zuckerman JD, Jones DA. Modular unipolar versus bipolar prosthesis: A prospective evaluation of functional outcome after femoral neck fracture. J Orthop Trauma. 1995;9:298–302.PubMedCrossRefGoogle Scholar
  69. 69.
    Raia FJ, Chapman CB, Herrera MF, et al. Unipolar or bipolar hemiarthroplasty for femoral neck fractures in the elderly? Clin Orthop. 2003;414:259–65.PubMedCrossRefGoogle Scholar
  70. 70.
    Bhandari M, Devereaux PJ, Tornetta 3rd P, et al. Operative management of displaced femoral neck fractures in elderly patients. An international survey. J Bone Joint Surg Am. 2005;87(9):2122–30.PubMedCrossRefGoogle Scholar
  71. 71.
    •• Moran CG, Wenn RT, Sikand M, et al. Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am. 2005;87(3):483–9. Showed an increased mortality in patients who were fit for surgery and delayed up to 4 days. Patients with medical comorbidities had a 2.5 fold increase in mortality at 1 month, 3 months, and 1 year regardless of delay. Highlights risks of surgical delay and significance of comorbidities. PubMedCrossRefGoogle Scholar
  72. 72.
    Zuckerman JD, Skovron ML, Koval KJ, et al. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995;77(10):1551–6.PubMedGoogle Scholar
  73. 73.
    Shiga T, Wajima Z, Ohe Y. Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anesth. 2008;55(3):146–54.PubMedCrossRefGoogle Scholar
  74. 74.
    Hommel A, Ulander K, Bjorkelund KB, et al. Influence of optimized treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year. Injury. 2008;39:1164–74.PubMedCrossRefGoogle Scholar
  75. 75.
    Bottle A, Aylin P. Mortality associated with delay in operation after hip fracture: observational study. BMJ. 2006;332(7547):947–51.PubMedCrossRefGoogle Scholar
  76. 76.
    Radcliff TA, Henderson WG, Stoner TJ, et al. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J Bone Joint Surg Am. 2008;90(1):34–42.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryUC Davis Medical CenterSacramentoUSA

Personalised recommendations