Summary Femoral neck fractures are common injuries to the proximal femur associated with increased risk of avascular necrosis, and high levels of patient morbidity and mortality. Diagnosis is generally made radiographically with orthogonal radiographs of the hip. Treatment is generally operative with open reduction and internal fixation versus arthroplasty depending on the age of the patient, activity demands and pre-injury mobility. Epidemiology Incidence common login to view 1 more bullet Demographics women > men Caucasians > African Americans United states has highest incidence of hip fx rates worldwide Etiology Pathophysiology healing potential login to view 3 more bullets Mechanism high energy in young patients low energy falls in older patients Associated injuries femoral shaft fractures login to view 2 more bullets Anatomy Osteology normal neck shaft-angle 130 +/- 7 degrees normal anteversion 10 +/- 7 degrees Blood supply to femoral head major contributor is medial femoral circumflex (lateral epiphyseal artery) some contribution to anterior and inferior head from lateral femoral circumflex some contribution from inferior gluteal artery small and insignificant supply from artery of ligamentum teres displacement of femoral neck fracture will disrupt the blood supply and cause an intracapsular hematoma (effect is controversial) Classification Garden Classification (based on AP radiographs and does not consider lateral or sagittal plane alignment) Type I Incomplete fx (valgus impacted) Type II Complete fx, nondisplaced Type III Complete fx, partially displaced Type IV Complete fx, fully displaced Simplified Garden Classification Nondisplaced Includes Garden I and II Displaced Includes Garden IIII and IV Pauwels Classification (based on vertical orientation of fracture line) Type I < 30 deg from horizontal Type II 30 to 50 deg from horizontal Type III > 50 deg from horizontal (most unstable with highest risk of nonunion/AVN) Presentation Symptoms impacted and stress fractures login to view 1 more bullet displaced fractures login to view 1 more bullet Physical exam impacted and stress fractures login to view 3 more bullets displaced fractures login to view 1 more bullet Imaging Radiographs recommended views login to view 4 more bullets optional views login to view 1 more bullet CT indications login to view 1 more bullet MRI indications login to view 2 more bullets Bone scan indications login to view 2 more bullets Duplex Scanning indications login to view 1 more bullet Treatment Nonoperative observation alone login to view 2 more bullets Operative closed reduction with cannulated screw fixation login to view 6 more bullets open reduction internal fixation (ORIF) login to view 11 more bullets hemiarthroplasty login to view 8 more bullets total hip arthoplasty login to view 6 more bullets Techniques General Technical Principles time to surgery login to view 6 more bullets anesthesia type login to view 2 more bullets treatment approach based on login to view 3 more bullets Closed reduction with cannulated screw fixation technique login to view 11 more bullets Open reduction internal fixation (ORIF) approach login to view 17 more bullets reduction login to view 10 more bullets fixation login to view 8 more bullets Hemiarthroplasty approach login to view 2 more bullets technique login to view 3 more bullets Total Hip Replacement technique login to view 1 more bullet advantages login to view 1 more bullet complications login to view 2 more bullets Complications Osteonecrosis incidence of 10-45% recent studies fail to demonstrate an association between time to fracture reduction and subsequent AVN increased risk with login to view 5 more bullets treatment login to view 5 more bullets Nonunion incidence of 5 to 30% login to view 2 more bullets varus malreduction most closely correlates with failure of fixation after reduction and cannulated screw fixation. treatment login to view 10 more bullets Dislocation higher rate of dislocation with THA (~ 10%) login to view 1 more bullet risks of dislocation after a hemiarthroplasty login to view 3 more bullets Failure rates high early failure rates in fixation group, which stabilizes after 2 years login to view 5 more bullets overall failure rates still higher in fixation vs. arthoplasty at 10-year follow-up sliding hip screw with lower reoperation rates compared to cannulated screws login to view 3 more bullets Reducing complications with co-management service orthopaedic geriatric co-management of trauma patients has been demonstrated to yield login to view 2 more bullets important to mitigate risks of hospital delirium which may lead to increased length of stay Loss of independence requiring walking aids and assisted living following fracture surgery login to view 3 more bullets associated factors login to view 7 more bullets Prognosis Most expensive fracture to treat on per-person basis Mortality ~25-30% at one year (higher than vertebral compression fractures) Predictors of mortality pre-injury mobility is the most significant determinant for post-operative survival in patients with chronic renal failure, rates of mortality at 2 years postoperatively, are close to 45% mortality risk is decreased at 30 days and at 1 year post-op when surgical intervention is performed within 24 hours of admission