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Fracture of the Femoral Neck

Epidemiology

  • More common due to ageing population
  • Higher preponderance in women and Caucasians

Etiology

  • High energy trauma – younger patients
  • Low energy trauma (falls) – older patients
  • Associated injuries – femoral shaft fractures

Anatomy

  • Normal neck-shaft angle – 130o
  •    Blood supply – originates from deep femoral artery, gives off two branches
    • Medial and lateral femoral circumflex arteries – they loop around the base of the femoral neck to form the extracapsular ring
    • This gives off several small ascending cervical branches which penetrate the capsule – run proximally within the joint, close to the femoral neck
    • When they reach the articular surface they form the subsynovial intracapsular ring

Pathophysiology

  • The femoral neck is the weakest part of the femur
  • Fracture of the femoral neck is classified as an intracapsular fracture (extracapsular fractures include intertrochanteric, trochanteric and subtrochanteric fractures)
    • Intracapsular fractures usually do not unite, in contrast to extracapsular
  • Type of fracture – according to anatomical location
    • Subcapital – just below the head (worst prognosis)
    • Transcervical – middle of the neck
    • Basal – at the base of the neck

Classification –  Garden Classification

  • Type I – incomplete
  • Type II – complete, nondisplaced
  • Type III – complete, partially displaced
  • Type IV – complete, fully displaced

Clinical features

  • Nondisplaced fracture
    • Slight pain in groin; referred pain along medial thigh and knee
    • No obvious deformity
    • Minor discomfort with range of motion
  • Displaced fracture
    • Pain in entire hip
    • Leg in external rotation and abduction
    • Shortening

Diagnosis

  • X-ray – nondisplaced fracture may be subtle on X-ray
  • CT – for comminuted or severely displaced fractures
  • MRI or Tc99 – rarely indicated

Treatment

  • Observation – for patients with minimal pain or those who are at high risk for surgery
  • ORIF – displaced fractures in young patients
  • Cannulated screw fixation – nondisplaced cervical fracture
  • Sliding hip screw – basal/cervical fracture
  • Hemiarthroplasty
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