Femoral Neck Fracture

Snapshot

• A 71-year-old woman with a past medical history of diabetes, alcohol use disorder, and dementia presents to the physician’s office after tripping and falling yesterday. Since falling, she reports that she has had significant right hip and groin pain. She reports not being able to walk anymore and had to use a wheelchair. Physical exam reveals a tender right hip, limited range of motion of the affected limb, and pain elicited with the log roll maneuver. She is sent immediately for an orthopedic consult.

Introduction

• Clinical definition
  • fracture of the femoral neck
• Epidemiology
  • demographics
    • female > male
    • more common in older patients
    • rare in young patients
  • location
    • femoral neck
    • main blood supply to the femoral head is the medial circumflex femoral artery
  • risk factors
    • older age
    • osteoporosis
    • primary bone disease
• Etiology
  • acute trauma
    • minor trauma, such as falls, in elderly patients who are prone to osteoporosis
    • high-energy trauma in young patients
  • repetitive stress
• Associated conditions
  • osteoporosis
• Prognosis
• immediate surgical repair is associated with better outcomes

Presentation

• Symptoms
  • severe hip, groin, or thigh pain
  • often presents with a history of recent trauma or fall
• Physical exam
  • involved leg is abducted and externally rotated and may appear shortened
  • hip is tender to palpation
  • hip pain is elicited with active and passive range of motion
    • involved hip has a limited range of motion
  • log roll maneuver  
    • with the patient supine, the clinician internally and externally rotates the leg
    • elicited hip pain with this maneuver suggests a femoral neck fracture
• patients may still be able to ambulate

Imaging

• Radiography  
  • indication
    • for all patients
  • recommend views
    • anteroposterior radiograph of pelvis
    • lateral radiograph of hip
    • avoid frog-leg radiograph as positioning may cause severe pain and increase displacement
  • findings
    • fracture of the hip
    • loss of trabecular pattern of the femoral neck
• abnormal neck-to-shaft angle (normal is 125°)

Studies

• Making the diagnosis
  • based on clinical presentation and imaging
• there is a high index of suspicion for a fracture of the femoral neck even with a negative radiograph in an elderly patient with osteoporosis

Differential

• Osteonecrosis of femoral head
  • distinguishing factors
    • radiography does not reveal a femoral neck fracture
• physical exam does not elicit hip pain with passive or active motion or with the log roll maneuver

Treatment

• Management approach
  • approach includes management of pain, immobilization of the leg and hip, and surgical correction
  • currently, there is debate as to whether open reduction with internal fixation or arthroplasty is the best option
• Conservative
  • immobilization
    • indication
      • for all patients while awaiting surgery
• Medical
  • intravenous analgesic medication
    • indication
      • for pain management
    • modalities
      • opioids, as pain from a femoral fracture is very severe
• Operative
  • open reduction and internal fixation (ORIF)
    • indications
      • in younger patients
      • all displaced fractures
  • hip arthroplasty 
    • indications
      • in older patients
• when surgery is contraindicated

Complications

• Increased mortality
• Avascular necrosis of femoral head 
  • displacement of femoral neck fracture will disrupt the blood supply and is associated with avascular necrosis of the femoral head
• Osteoarthritis