Emergent Treatment.

After adequate physical examination, review of the AP pelvic radiograph for location of the femoral head fracture, and evaluation of the femoral neck and acetabulum, early gentle closed reduction is recommended. Closed reduction of the hip is indicated for all hip dislocations regardless of whether an associated femoral head fracture is present. Techniques for closed reduction are outlined in Chapter 52 . Delay must be avoided to minimize the risk of posttraumatic AVN of the femoral head. If a femoral neck fracture is identified, it is probably better to forego any attempt at closed reduction and proceed with open surgery after an urgent preoperative CT scan, if possible. Such an approach may decrease the risk of displacement of the femoral neck fracture with further injury to the vascular supply of the femoral head.

If closed reduction is unsuccessful in the emergency department, then patient should be taken to the operating room for a closed versus open reduction under complete muscle relaxation. A preoperative CT scan, whenever possible, helps alert the surgeon to intraarticular fragments, acetabular or femoral neck fractures, and the size of the femoral head fragment. A delay of more than an hour to obtain a CT scan should be avoided. Percutaneously placing a 5-mm Schanz pin in the proximal femur can provide better leverage than purely manual traction alone for those irreducible dislocations ( Fig. 54-4 ). If unsuccessful, then an open approach should be performed. In general, posterior dislocations should be reduced through a posterior approach. The external rotators and buttonholed capsule are the usual structures blocking reduction. Intraarticular fragments can be removed with this approach, and associated posterior wall acetabular fractures can be operatively reduced under direct vision. Internal fixation of the femoral neck and head, as well as reduction of these fractures, is difficult with this approach. The patient should be placed in the lateral decubitus position to allow access to the anterior aspect of the pelvis should a simultaneous approach be necessary to reduce and internally fix the femoral head fragment. A simple technique of obtaining hip distraction is using a 5-mm Schanz pin placed in the proximal femur. The 5-mm Schanz pin is placed laterally at the level of the vastus ridge. The assistant who will be distracting the hip will stand anterior to the patient. With the hip in neutral extension and the knee flexed at 60 to 90 degrees, the assistant has one arm cradled around the knee and the other hand on the T-handle chuck. The assistant can provide a significant amount of hip joint distraction to allow the surgeon to remove loose bodies and assess the femoral head. This technique allows for more freedom to externally and internally rotate the hip joint to better visualize the hip joint. Another technique is a femoral distractor applied from the iliac crest to the proximal femoral shaft, which helps gain distraction of the hip joint to improve visualization of the reduction. Without performing a surgical hip dislocation, it is difficult to attempt fixation of the femoral head, which is generally medially located. If the surgeon chooses to leave the femoral head fragment unfixed, the patient should be treated by skin or light skeletal traction for 3 to 6 weeks ( Fig. 54-5 ).

Irreducible hip dislocation. A, A 31-year-old male was in a motor-vehicle accident and sustained a left femoral head fracture, posterior hip dislocation, and associated posterior wall acetabular fracture. B, Repeat anterior-posterior (AP) pelvis showed unsuccessful reduction attempt in the emergency department. C and D, Computed tomographic (CT) showed a locked femoral head dislocation with an associated posterior wall acetabular fracture. E and F, Intraoperative C-arm images of a 5-mm Schanz pin that was percutaneously placed in the proximal femur. This pin assisted the closed reduction by providing better leverage with rotation and traction to reduce the locked dislocation. Ideally, this pin should be placed above the level of the lesser trochanter. The patient was placed in skeletal traction until definitive fixation was performed by an acetabular-pelvis specialist.

Traction treatment of a femoral head fracture. A, This 23-year-old man sustained a posterior dislocation of his hip in a motor-vehicle accident. Because of an inability to perform closed reduction of the hip dislocation, he underwent open reduction under general anesthesia. The femoral head fragment was not visualized. B and C, The ensuing anatomic reduction of the femoral head fragment was confirmed by computed tomography. The patient was treated by traction for 3 weeks, followed by touch-down weight-bearing for 3 additional weeks, and has excellent range of motion without any sign of osteonecrosis or degenerative hip disease at long-term follow-up.

Recently Mehta and Routt reported seven cases of irreducible fracture-dislocation of the femoral head without posterior wall acetabular fractures. The physical examination and radiographic findings in this rare injury depicted a different appearance than the standard posterior hip dislocation. The injured limb is shortened, slightly flexed at the knee and hip, and in neutral rotation. Imaging studies showed the suprafoveal femoral head fractures retained in the acetabulum while the dislocated proximal femur is locked against the lateral iliac cortical bone of the supraacetabular region. The dislocated component had buttonholed through the posterior–superior labral and capsular tissues and impacted in the acetabulum. In this series, all seven patients underwent ORIF via a Smith-Petersen surgical approach.

Special Considerations for Patients with Polytrauma.

An unreduced hip dislocation is a musculoskeletal emergency because of the consequences of posttraumatic femoral head necrosis, which increases in incidence with increasing duration of the dislocation. An AP pelvic radiograph is part of the initial evaluation of a patient with multiple injuries and will reveal the hip dislocation plus the femoral head fracture. If the patient is going to the operating room for head, abdominal, or chest procedures, closed reduction of the hip dislocation can be expedited by the orthopaedist’s presence following induction of anesthesia. As soon as muscle relaxation has been achieved and the airway secured, closed reduction of the hip is performed as described in Chapter 52 . If unsuccessful, open reduction should be performed as soon as other lifesaving procedures are completed. If closed reduction is successful, the same algorithm of postreduction CT followed by ORIF of a poorly reduced fracture, débridement of loose bodies, or ORIF of the femoral neck or acetabulum is used. In the case of an associated unrecognized femoral neck fracture or loose bodies, an open procedure should follow as soon as the patient can tolerate a second anesthetic. This open procedure is performed to avoid damage to the articular surfaces in the case of small loose fragments of bone or cartilage and to lower the risk of AVN of the femoral head in the case of the femoral neck fracture. Skeletal traction should be initiated in the interim when loose fragments are identified to minimize damage to the articular cartilage. Delayed operative management has been reported with good functional outcome.

In patients with well-reduced femoral head fractures of the Pipkin type I or II classification, it may be advisable to perform ORIF of the femoral head fragment to allow the patient to be mobilized. Traction, in general, should be avoided in patients with serious thoracic trauma or pulmonary dysfunction. The ability to mobilize patients with multiple injuries has been shown to have the positive benefit of reducing the incidence of pulmonary failure and sepsis.

Indications for Definitive Care.

The goals of treatment for femoral head fractures are to achieve a reduction with residual displacement of 1 mm or less and a stable and congruent hip joint. For isolated Pipkin type I fracture with excellent (less than 1-mm step-off) reduction, closed treatment is recommended. One to 4 weeks of light traction (Buck’s skin traction or skeletal traction) followed by touch-down weight-bearing on crutches for 4 weeks has produced good results in most patients. If the reduction is not adequate, ORIF with small cancellous bioabsorbable or Herbert screws is recommended, using an anterior approach. Herbert screws provide less compressive force across large cancellous surface areas than do standard small-fragment screws. In polytrauma cases, ORIF may also be indicated even when the reduction is good to allow mobilization of younger patients.

The same recommendations apply to type II fractures, but because of involvement of the superior femoral head, only an anatomic reduction on repeated radiographic evaluations should be accepted for conservative care. For cleavage femoral head fractures associated with a femoral neck fracture (Pipkin type III), the prognosis is poor. The prognosis for the injury in regard to posttraumatic AVN of the femoral head is related to the degree of displacement of the femoral neck fracture. For this reason, care must be taken during closed reduction to prevent displacement of a recognized or unrecognized femoral neck fracture ( Fig. 54-6 ). In a younger, more active patient, urgent ORIF of a type I or II femoral head fracture through an anterior Smith-Petersen approach is recommended, along with screw fixation of the femoral neck fracture. Surgical dislocation has been recently reported to provide excellent visualization of the fracture for reduction and fixation. The decision to proceed in this manner should be weighted toward treating those who are active, are physiologically young, and have minimally displaced or nondisplaced femoral neck fractures. In patients who do not fulfill these criteria, a bipolar endoprosthesis or total hip arthroplasty (THA) should be performed.

Combined fractures of the femoral head and neck. A, This 24-year-old male was an unrestrained passenger in a motor-vehicle accident. He sustained a femoral head fracture with posterior hip dislocation. B, Attempted closed reduction in the emergency department resulted in a new femoral neck fracture or displaced a previous nondisplaced femoral neck fracture (computed tomography [CT] scan inconclusive). Patient also has an associated left acetabular fracture and an anterior-posterior compression III pelvic ring injury. C, Open reduction and internal fixation (ORIF) was performed of the combined femoral head and neck fractures and the left acetabular fracture via an iliofemoral and a modified Stoppa approach. Bilateral sacroiliac joint diastases were fixed with percutaneous iliosacral screws. D, At 5 months’ follow-up, the patient had groin pain and changes consistent with osteonecrosis of the proximal end of the femur, a complication that was expected. He underwent hip arthroplasty 2 years later.

Pipkin type IV fractures must be treated in tandem with the associated acetabular fractures. The acetabular fracture should dictate the surgical approach, and the femoral head fracture, even if it is nondisplaced, should be internally fixed to allow early motion of the hip joint. Management of the associated acetabular fracture is covered in Chapter 41 .

Femoral head fractures associated with anterior hip dislocations are very difficult to manage. Elevation of the indentation fragment has been advocated, but the long-term results of this technique have not been published. The prognosis is poor because of the risk of posttraumatic arthritis, and the patient should be so informed. Cleavage fractures, if they are large and noncomminuted, may be internally fixed. The repair should be performed from an anterior approach if the CT scan indicates that the major portion of the fragment is anterior and from a posterior approach if the fragment involves the posterior, weight-bearing portion of the femoral head. No results with this treatment have been published.

Nonoperative Treatment.

If closed reduction is successful, a postreduction CT scan is indicated. The scan is then reviewed for reduction of the fragment, status of the femoral neck and acetabulum, and presence of loose bodies. Treatment recommendations are then based on the classification, reduction of the fracture, and general considerations. Traditionally, skeletal traction is applied and 6 weeks of bed rest is recommended. However, complications such as decubitus ulcer, DVT, and pneumonia can occur with prolonged bed rest. Ideally patients that are treated nonoperatively should be allowed to mobilize with touch-toe weight-bearing (TTWB) and regular repeated radiographs should be obtained to evaluate for maintenance of reduction and hip joint congruency.

Surgical Treatment

Treatment

Fragment Excision.

In combination with closed or open reduction, the indications for fragment excision are severe comminution and interposition of a small femoral head fragment between the femoral head and acetabulum. Excision of the fragment can be accomplished through the same surgical approach used for open reduction. Fragment excision can also be accomplished arthroscopically in the hands of surgeons experienced with hip arthroscopic techniques. If done subsequent to reviewing the CT scan after closed reduction, the open surgical approach is dictated by the location of the fragments. Anterior and inferior fragments should be approached through the Smith-Petersen interval. In the case of interposed fragments, excision is urgent and the procedure must be done quickly to avoid further damage to the articular surfaces.

Open Reduction and Internal Fixation.

ORIF is indicated for all fractures with residual displacement of 1 mm or more, for fractures associated with femoral neck or acetabular fractures, and for fractures with large femoral head fragments that require open reduction of the associated hip dislocation. For most Pipkin type I and II fractures, ORIF should be performed through an anterior Smith-Petersen approach ( Fig. 54-7 ). The surgery is performed with the patient in the “semilateral” position and a large pad underneath the affected hip. These procedures should be performed within several days after closed reduction and a postreduction CT scan. In the case of a posterior approach, fragments off the anterior aspect of the femoral head are difficult to visualize, are harder to reduce, and can be nearly impossible to fix internally. This approach was recommended by Epstein and coworkers because of fear of damage to the blood supply to the femoral head from the anterior capsule. The blood supply to the femoral head from this source is negligible, and because of these operative difficulties, the anterior approach is favored. The patient may be treated in a continuous passive-motion machine postoperatively, along with 8 weeks of touch-down weight-bearing and avoidance of extreme hip flexion (>70 degrees) for 4 to 6 weeks. The anterior approach may be accompanied by heterotopic ossification of functional significance. Such ossification can be avoided by minimizing stripping of the tensor fasciae latae and abductor musculature from the ilium. Indomethacin (Indocin), 25 mg orally three times a day for 6 weeks, or low-dose irradiation may also have a favorable influence, but diphosphonates are probably of limited therapeutic value ( Fig. 54-8 ).

Anterior (Smith-Petersen) approach for open reduction and internal fixation of a femoral head fracture. A, Skin incision. The leg is draped free for manipulation. B, Exposure of the deep fascia and release of the abductors from the iliac crest. C, Development of the interval between the sartorius and the tensor fasciae latae, which is usually palpable with a finger. D, Identification, division, and ligation of ascending branches of the lateral femoral circumflex vessels in the distal portion of the wound and release and suture tag of the direct and reflected heads of the rectus femoris to define the hip capsule. E, Elevation and reflection of the rectus femoris to expose the anterior hip capsule in its entirety. F, By releasing the hip capsule from its trochanteric attachment and incising longitudinally along the anterior of the femoral neck, arthrotomy reveals the femoral head fracture. Sutures placed at the edges of the capsulotomy are useful for retraction to enhance exposure. By flexing and maximally externally rotating the limb, the reduction can be assessed and adjusted. This exposure permits fixation with small lag screws recessed below the articular surface.

Internal fixation of a femoral head fracture from an anterior approach. A and B, This 44-year-old man was involved in a high-speed motor-vehicle accident in which he sustained an open mandibular fracture, multiple rib fractures, pneumothorax, and this posterior hip dislocation with a Pipkin type II femoral head fracture. On admission, he was taken emergently to the computed tomography (CT) scanner for an intra-abdominal scan before reduction of the hip. C and D, Closed reduction of the hip dislocation was successful. E, Because of his pulmonary injuries, which required ventilation, it was thought that open reduction and internal fixation (ORIF) was indicated to mobilize the patient. Therefore, he underwent ORIF through an anterior Smith-Petersen approach on the day of admission. F, The patient was mobilized postoperatively, extubated on the fourth postoperative day, and limited to touch-down weight-bearing for 12 weeks. At 3 years’ follow-up, flexion was limited to 80 degrees because of heterotopic ossification. The patient has no pain and does not desire to have the heterotopic ossification resected. Heterotopic ossification has been related to stripping of the abductor muscles off the lateral aspect of the ilium; such stripping is no longer recommended.

Prosthetic Replacement.

Prosthetic replacement is indicated in a Pipkin type III fracture when the patient is physiologically elderly or the femoral neck fracture is markedly displaced in patients older than 50 or 60 years. Primary femoral head replacement is otherwise contraindicated and should be performed only after a trial of conservative care when the end result of internal fixation is joint incongruity or degenerative arthritis. Should such problems develop, total hip replacement is indicated. Details regarding the procedure of endoprosthetic replacement are discussed under the “Femoral Neck Fractures” section ( Fig. 54-9 ).

Prosthetic replacement for femoral head and neck fracture. A, This 55-year-old woman was involved in a rollover motor-vehicle accident and sustained a fracture of the femoral neck with an inferior femoral head fragment and dislocation of the major femoral head fragment. This lesion is not, strictly speaking, a Pipkin type III injury because of the dislocation of the femoral head. B, Because of the age of the patient, an uncemented bipolar prosthesis was selected as the treatment of choice. The patient had done reasonably well at 3 years’ follow-up; she has occasional groin pain, but the prosthesis has not been revised to a total hip replacement.

Open Reduction and Internal Fixation of Associated Acetabular Fractures.

ORIF of the acetabular fracture in a Pipkin type IV injury is indicated when the fracture is displaced or the hip reduction is unstable. The femoral head fragment should also be internally fixed to gain the benefits of early, relatively unrestricted joint motion. Whereas the main component of the acetabular fracture dictates the surgical approach, the femoral head fracture may require a separate anterior approach to accomplish the reduction and fixation. The details of operative management of an acetabular fracture are described in Chapter 41 .

Posterior Approach Surgical Hip Dislocation.

Surgical dislocation of the hip with a trochanteric flip osteotomy has been reported to provide excellent exposure for femoral head fractures. In concomitant femoral head and posterior wall fractures, the surgical hip dislocation approach can provide safe exposure for fixation of both fractures via a single approach. This approach provides full visualization of the acetabular socket and allows thorough irrigation and removal of small debris (capsule, labrum, bony fragments) in the hip joint. Careful attention to preserving the deep branch of the medial femoral circumflex artery (MFCA) is the key to minimizing the risk of AVN.

Surgical Anatomy.

The surgical anatomy is the same as the standard Kocher-Langenbeck approach, but with several important additions. A greater trochanteric osteotomy (digastric or slide osteotomy) is performed to maintain the insertion of the gluteus medius/minimus tendon and origin of the vastus lateralis on the greater trochanter. The vascular anatomy, specifically the course of the MFCA, is important to understand and preserve during this dissection. MFCA can be protected by avoiding the release of the short external rotators because the deep branch of the MFCA courses extracapsularly anterior to these structures before it enters the capsule to provide vascularity to the femoral head. The Z-shape capsulotomy described in the following “Surgical Approach” section is performed to facilitate controlled dislocation of the hip joint and allow full exposure of the femoral head and acetabular socket.

Positioning Techniques.

The surgical positioning is the same as the Kocher-Langenbeck approach. Adding a total hip drape will allow placement of the involved leg once the hip is dislocated anteriorly.

Surgical Approach.

A standard Kocher-Langenbeck approach is made. The interval between the piriformis tendon and gluteus minimus is identified. An electrocautery is used to mark a line at the posterior edge of the greater trochanter where the gluteus medius inserts and is extended distally on the posterior border of the vastus ridge. A wafer (1.5 cm) of bone is osteotomized off the greater trochanter in a digastric or slide fashion and the short external rotators are left intact to avoid injuring the MFCA branch. Using a fine-tooth oscillating blade (19.5 × 41 × 0.4 mm) and C-arm imaging can avoid taking too much or too little of the trochanter. Further release of the vastus lateralis distally off the proximal femur (to the level of the gluteus maximus tendon insertion) and remaining fibers of the gluteus minimus will allow the osteotomized segment to be retracted anteriorly with a Hohmann retractor. With the hip capsule exposed, a Z-shaped capsulotomy is made starting at the piriformis and the rim of the posterior acetabulum. The capsulotomy is extended from the posterior acetabulum to the anterior acetabulum and zigzags slightly posteriorly before extending down along the anterolateral femoral neck toward the lesser trochanter. Care should be taken to avoid further damage of the labrum ( Fig. 54-10 ). If there is a posterior wall acetabular fracture, a modification of the capsulotomy should be made to avoid removing the remaining capsular attachment to the wall fragment. The hip is dislocated anteriorly by pulling traction, flexing, and externally rotating the leg and putting the lower leg into the hip holder. Sometimes, carefully using a bone hook around the femoral neck or a 5-mm Schanz pin in the proximal femur may assist with dislocating the hip. The femoral head and the hip socket can be fully visualized for débridement, excision, reduction, and fixation. The femoral head is relocated with manual traction, internal rotation, and extension of the leg. Repair of the Z-shape capsulotomy is performed with nonabsorbable sutures. The greater trochanteric osteotomy is reduced and internally fixed with two 3.5-mm lag screws with washers ( Fig. 54-11 ).

A, Trochanteric osteotomy. The proximal interval is between the piriformis tendon and the gluteus medius. The line is cheated slightly toward the gluteus medius, and leaving several tendon fibers attached to the main fragment will ensure there is an adequate shelf of bone remaining to protect the external rotator insertions, and thus the critical blood supply. B, The capsulotomy incision is Z shaped, extending from the posterior acetabulum, down the anterolateral femoral neck to the level of the lesser trochanter.

(Redrawn from Gardner MJ, Suk M, Pearle A, et al: Surgical dislocation of the hip for fractures of the femoral head, J Orthop Trauma 19(5):334–342, 2005.)

Surgical hip dislocation for fixation of Pipkin IV fracture-dislocation. A, Anterior-posterior (AP) pelvis showed a femoral head fracture with a posterior hip dislocation. B1 and B2, AP pelvis with Judet views showed the displaced femoral head is located in the acetabular socket and there is an associated posterior wall fracture. C and D, Computed tomographic (CT) better delineated the posterior wall and femoral head fracture. E, F, and G, At 6 months’ follow-up after open reduction and internal fixation (ORIF) using a surgical hip dislocation technique to address both the femoral head and posterior wall acetabular fracture through the same approach.

Nonunion.

Nonunion is rare after nondisplaced or impacted fractures. However, after displaced fractures nonunion occurs in 50% to 60% of patients treated nonoperatively, and in 4% to 33% after internal fixation. Several studies have shown that nonunion is a rare problem in patients with normal bone density and in whom stable fixation is achieved. It is most closely associated with increased age and fracture displacement. Unstable fixation with poor reduction is generally the root cause. Most patients with femoral neck nonunions suffer moderate to severe groin or proximal thigh pain and limp, typically with a Trendelenburg gait. Because of pain and impaired gait, most patients will require a reconstructive procedure.

Avascular Necrosis.

As discussed earlier, femoral neck fractures, particularly if displaced, may damage the blood supply to the femoral head. The resulting postischemic scenario includes revascularization of the femoral head, with subsequent trabecular thinning and collapse. This has been called posttraumatic osteonecrosis, aseptic necrosis of the femoral head, late segmental collapse, and AVN . It occurs in 10% to 15% of patients with impacted or nondisplaced fractures and in 30% to 35% of patients with displaced fractures. Fracture displacement with damage to the arterial supply, as well as intracapsular tamponade, play a causative role. Some reports indicate that patients with normal bone density are at greater risk for this complication. This observation implies that a greater amount of force is involved in causing the fracture and that the displacement and soft tissue injury are therefore greater. Certainly, the incidence of AVN has been reported to be higher in younger adults with high-energy injuries. AVN in young adults has devastating complications because of the limited treatment options as compared to elderly patients. Older individuals with lower functional demands are less likely to but can have symptoms of groin and proximal thigh pain severe enough to warrant a reconstructive procedure in 35% to 50% of cases. Unlike the young adults, total hip replacement is a good option and has consistent good result for elderly patients with symptomatic osteonecrosis. Most agree that the higher the functional demands, the more likely it is that the patient will require a secondary procedure. Nearly all patients younger than 50 years in whom this complication develops require a reconstructive procedure. Their high functional demands and relatively young age make arthroplasty a difficult decision because of the high rates of complications and should be a last resort. The main goal of treatment for young patients with symptomatic femoral head osteonecrosis is to preserve the hip. Reconstructive options include osteotomy to unload the segmental area of femoral head collapse, femoral head core decompression, free vascularized bone grafting, and hip arthrodesis. Hemi-resurfacing of the femoral head is another option but only partially preserves the hip joint. Prevention is the best method for addressing these difficult problems and complications. Early surgery, anatomic reduction, and stable fixation are under the surgeon’s control and should be stressed to minimize further vascular injury to the femoral head. Although controversial, intracapsular decompression is easy to perform and may be beneficial with little chance it can negatively impact the outcome. Close monitoring with periodic radiographs are performed to look for femoral head osteonecrosis. An encouraging radiographic finding of viable femoral head is osteopenia on the injured side as compared with the normal side.

Pain.

Pain after a femoral neck fracture is minimized by stable internal fixation. Preoperative traction does not reduce pain and is to be discouraged. Parker and Handoll recently reported a review on 10 randomized trials evaluating preoperative traction (no traction, skin or skeletal traction) in hip fractures. They concluded that there is no evidence to support the benefit of traction for pain relief, ease of fracture reduction, or the quality of reduction. Groin or buttock pain that develops in the recovery period is generally associated with loss of stability and impending nonunion, or AVN. However, with modern fixation techniques, and accurate reduction, the incidence of nonunion is well below 10%, and thus the latter is more likely. The pain is probably caused by revascularization of the femoral head with resorption of dead trabeculae and associated microfractures ultimately leading to subchondral segmental collapse. An acute increase in pain without a traumatic event is typical of the final collapse of the segment. Pain can rarely be associated with postsurgical sepsis or injury to the sciatic nerve. In the late stages, pain can be caused by the development of posttraumatic degenerative arthritis, frequently related to segmental collapse and resultant loss of femoral head sphericity.

Limited Motion.

Limited hip motion is commonly associated with pain. The reason for this is that the position of maximal hip extension is avoided because this position decreases capsular volume and raises intraarticular pressure while placing maximal stress across the femoral neck. This symptom is therefore generally associated with nonunion or AVN. In the remote phase, true loss of motion caused by capsular fibrosis and osteophyte formation is a result of posttraumatic degenerative hip arthritis.

Impaired Mobility.

After hip fractures, half or more of patients older than the age of 50 years fail to regain their preoperative level of mobility. In some patients, it may result from complications of the fracture; in others, it may be from deterioration of their overall mental or physical condition. In many cases, this results in loss of independent living for an older patient. Successful return to independent living after hip fracture is best predicted by preinjury function in activities of daily living, absence of medical conditions that limit rehabilitation, and cognitive function. Women have lower mortality after hip fracture than do men from the first year throughout the first decade after hip fracture.

It may be assumed that differences among societies and medical care systems will influence the course and site of rehabilitation after femoral neck fracture. No convincing data have been published that demonstrate the superiority of any given form of treatment of femoral neck fracture with regard to outcome measured by the ability to walk or by the rate of institutionalization. Rehabilitation strategies to improve hip fracture outcomes have been identified as a research priority. Patients with senile dementia have significantly worse functional outcomes and higher mortality rates.

Medical Complications.

Medical complications associated with femoral neck fractures increase with age and severity of medical comorbidities of the patient at injury. One prospective review demonstrated that major medical complications occurred in 9% of patients who were healthy before the fracture and in 21% of patients with medical comorbidities (64% of these patients died). Potential complications include urinary tract infection, wound infection, ileus (occasionally with a risk of cecal rupture), mental status changes, stroke, myocardial infarction, pneumonia, DVT, pulmonary embolism, and death.

For older patients with hip fractures, a full medical evaluation must be performed and treatment instituted to deal with dehydration, electrolyte imbalance, and pulmonary dysfunction. Delirium is common in patients with hip fracture. One study revealed a prevalence of 9.5% early in the hospitalization and 53% postoperatively. The risk of medical complications is favorably influenced by early surgery and mobilization. However, the findings of Kenzora and coworkers and Eiskjaer and Ostgard of a higher rate of mortality in patients undergoing surgery the first day after injury emphasize the need for adequate medical evaluation and preoperative treatment of correctable medical conditions. Treatment protocols have been developed that use physiologic status scores to select patients with better physiologic status for internal fixation.

DVT is not uncommon after hip fracture, with one series reporting a rate of 23% in patients treated with standard means of prophylaxis (aspirin or warfarin). The vast majority of investigators have identified prophylaxis as a favorable influence on the rate of DVT. Dextran, warfarin, subcutaneous heparin therapy, phenindione, aspirin, dihydroergotamine, low-molecular-weight heparin, and intermittent compression boots have all been reported to decrease the incidence of DVT. Limb elevation and early patient mobilization also favorably influence the rate of thrombosis. Some form of prophylaxis against DVT and pulmonary embolism should be instituted in the preoperative or early postoperative period. Ultrasonographic scanning is the diagnostic technique of choice for the diagnosis of lower extremity DVT because of its high sensitivity and specificity. Despite agreement on the appropriateness of DVT prophylaxis, significant variation in use remains apparent.

A low serum albumin level and total lymphocyte count is associated with a higher risk of mortality and poor functional outcome in older patients. Nutritional supplements have been shown to play an important role in aiding recovery and minimizing wound healing complications. Medical consultation should be sought preoperatively and again with any sign of postoperative complications to minimize the effect of these problems (see Chapter 53 ).

Mortality.

An increased mortality rate over that of the general population after femoral neck fracture has been confirmed in numerous studies. Higher rates of mortality are apparent for patients with medical comorbidities and for males. There is some evidence to suggest that smaller rural hospitals have higher in-hospital mortality rates than larger urban hospitals. In the large series of Barnes, the mortality rate in the first month after surgery was 13.3% in men and 7.4% in women. The mortality rate increased significantly when the surgery was delayed beyond 72 hours. Similarly, in a large Norwegian series published by Dahl, the figures were 17.1% for males and 9.8% for females in the first month after fracture. When compared with an age-matched population, the mortality rate was 15 times greater in the first month and 7 times greater in the second month and thereafter followed the population trends. Kenzora and colleagues found a mortality rate of 13% at 1 year in the femoral neck fracture population versus 9% for age-matched controls. Eiskjaer and Ostgard identified the following factors (in order of decreasing importance) as influencing mortality in a series of 204 patients treated with cemented bipolar hemiarthroplasty: cardiac factors, status as a nursing home patient, chronic pulmonary disease, serum creatinine value greater than 1.7 mg/dL, pneumonia, previous myocardial infarction, duration of surgery, and gender. These medical comorbidities do not completely explain the increase in hospital mortality risk in patients with femoral neck fracture. Low admission hemoglobin (<12.0 g/dL in females, <13.0 g/dL in males) is a marker of chronic disease and has been identified as a significant predictor of higher length of hospital stay and increased 6- and 12-month mortality. Diabetes increases the risk of in-hospital mortality. Darner has developed predictive mortality scales and has determined that impaired mobility after fracture is the highest or best predictor of death. The finding of higher mortality in nursing home patients has been confirmed in the North Sydney “fractured neck of femur” outcomes project. The following factors had no influence on mortality: age, time delay from admission to surgery, mode of anesthesia, and cerebrovascular disease. Equivalent mortality rates for patients who had a prefracture cerebrovascular event has been confirmed by Youm and associates. The overall mortality rate in their series was 20% at 6 months and 28% at 1 year. Obesity may lessen the risk of dying. Holmberg and coworkers confirmed the clinical suspicion that patients who sustain their femoral neck fractures in institutions have higher mortality (three times) than do those who are injured at home. Similarly, patients with senile dementia have a mortality rate 21% higher than controls who do not have dementia. Dementia, delirium, and depression all increase the risk of mortality. Patients with multiple medical complications after surgery have the highest risk of dying.

Patients with a second femoral neck fracture have a higher mortality rate than is seen after a first such fracture. This was confirmed by Boston, who found a 3-month mortality rate of 30% after the second fracture versus 13% for a single such injury. Several studies have suggested that the mortality rate is higher after prosthetic replacement than after internal fixation. In addition, Chan and Hoskinson found a higher mortality rate after a posterior approach for prosthetic replacement (20.6%) than after an anterior approach (6.5%). Despite the high mortality rate after femoral neck fracture, 1-year mortality rates are higher with intertrochanteric fractures than with intracapsular fractures (38% vs. 29%, in one study). Poor nutrition as a factor in mortality impacts men more than women. Smoking and alcohol abuse affect both sexes equally. Patients in their 90s and older do not have higher mortality rates, but are at greater risk for losing independence and function. Deaths after hip fracture are frequently attributable to venous thromboembolisms (VTEs), and nutritional and pulmonary dysfunction. Thus, VTE prophylaxis, supplemental nutrition, and early mobilization of the patient are warranted.

In summary, minimizing medical complication goes beyond just performing surgical fixation or arthroplasty for elderly hip fractures. Multidisciplinary and comanagement approaches, such as fracture liaison services between the orthopaedic surgeon and medical specialist or hospitalist, are imperative to improving care of the geriatric hip fractures. Preoperative considerations should also include the involvement of nursing staff, rehabilitation specialists, nutritionists, social workers, pain management specialists, and family members (if available). Integration of all these crucial healthcare providers can significantly reduce the high morbidity and mortality that often accompany these injuries.

History.

In the case of a young patient involved in a high-velocity crash, information about the event is helpful in directing the clinical and radiographic evaluation. The physical and radiographic examinations, however, are usually more valuable than the history for directing evaluation and treatment. An accurate history may contribute more to the evaluation of the much more frequent low-energy femoral neck fracture of older individuals. Information concerning medications, medical conditions, and activity level is important. One should always ask whether the patient had pain in the groin or proximal part of the thigh before the fracture, as such pain may suggest the presence of some type of pathologic fracture.

For these elderly, occasionally demented patients, it is essential to obtain a reliable description of the patient’s activity level before injury. Did she or he walk independently? Was the patient able to assist with transfers from bed to chair? This information helps the physician choose between internal fixation of the fracture and prosthetic replacement. Overall prognosis is influenced by the patient’s preinjury functional level, preexisting medical problems, and, especially, mental status.

In addition, in an older patient, it is critical to evaluate risks and treatment opportunities for osteoporosis and for fall prevention. Switzer and associates reported suggestions on overcoming barriers to osteoporosis care in order to minimize future fractures. Effective osteoporosis care for the vulnerable hip fracture patient starts with identification, diagnoses, and workup of hip fracture patients in the acute care hospital setting. This can be initiated by an established coordinator-managed program, system modification, or automatic specialist referrals. Ultimately, vulnerable hip fracture patients are discharged on appropriate supplements and medication. Caregivers and primary care physicians should be made aware and appropriate follow-up should be made to ensure or improve adherence with the treatment recommendations.

Physical Examination.

Evaluation of a patient involved in high-energy trauma is covered in Chapter 9 . For femoral neck fractures associated with minor falls, the examination can be conducted in a more focused manner. The presence of a femoral neck fracture may be apparent from the attitude of the affected leg, such as obvious shortening, external rotation, and reluctance to move the limb. Alternatively, usually with an undisplaced fracture, the injury may be occult and suggested only by the patient’s complaints of groin, thigh, or (rarely) lateral hip pain. Tenderness in the hip region produced by percussion on the sole of the foot with the fist or pain at the extremes of hip motion, particularly rotation, may be the only local physical findings to suggest such an occult hip fracture.

After evaluating vital signs and mental status, the head and neck examination should focus on areas of tenderness, evidence of contusions or abrasions, and decreased cervical ROM. If any of these findings is present, a hard cervical collar should be applied until the cervical spine can be cleared radiographically. The chest should be palpated for signs of rib fracture and auscultated to rule out pneumothorax. A screening examination of the upper and lower extremities should follow, with palpation and with the patient, if alert, putting the joints through a ROM. The examination should then focus on the affected lower extremity. The trochanteric region should be evaluated for contusions and for traumatic or nontraumatic skin conditions that might influence surgical management. The knee should be examined for tenderness, effusion, and instability. If such evaluation is not possible because of thigh pain, the knee examination must be repeated before the surgical procedure but after initiation of anesthesia. The thigh and leg should be palpated and the foot and ankle examined for signs of trauma. The circulatory status of both limbs should be assessed as a baseline for follow-up evaluations and the status of the pulses carefully recorded. Finally, a complete sensory and motor examination of the limb should be performed and the findings on physical examination detailed in the medical record.

Plain Films.

Radiographic evaluation should include AP and lateral plain radiographs of the entire femur as well as an AP radiograph of the pelvis. For patients involved in high-energy injuries, an AP radiograph of the pelvis is routinely obtained as part of the early trauma series of radiographs. The proximal femur should always be carefully scrutinized. When possible, the legs should be taped at the ankle level to hold the hips in internal rotation before obtaining this film. Physical or radiographic findings of ipsilateral leg trauma, or the presence of hip pain, is also an indication for a routine AP pelvic radiograph.

In the low-energy setting, with history or examination suggesting a hip fracture, an initial AP pelvic radiograph, with the legs taped or held in gentle internal rotation, should be obtained and carefully inspected for a femoral neck fracture. If a hip fracture is suspected but is not evident on this initial radiograph, proceed with imaging studies as discussed later. Nonpathologic high subcapital fractures can be misinterpreted as pathologic fractures in 17% of plain radiographs. An estimate of osteoporosis should be made with the Singh index (using the intact contralateral hip) because this index has some predictive value regarding the degree of osteoporosis and the potential for obtaining stable internal fixation.

If a fracture is evident or suspected on clinical grounds, a cross-table lateral radiograph of the affected limb is also required. This radiograph is made with the affected limb remaining on the stretcher while the good limb is flexed up and out of the x-ray beam. The lateral view should be scrutinized for posterior femoral neck comminution because this view likewise affects the prognosis for obtaining stable internal fixation. Obtaining a traction and internal rotation radiograph has been shown to improve resident ability to classify proximal femur fractures. Koval and associates reported that if properly performed by a trained physician, this traction view can better delineate the fracture and assist with surgical preoperative planning. The fracture patterns seen in elderly patients are different from those seen in young patients. Elderly patients with poor bone quality and low-energy injury mechanisms will usually sustain a femoral neck fracture that will often be subcapital. Commonly, the fracture pattern is a transverse fracture with impaction at the fracture site. In contrast, young patients with good bone quality and high-energy mechanisms will often sustain a basicervical or more distal neck fracture. The fracture pattern is more biomechanically unstable because of the vertically oriented fracture position. These characteristics have important implications when obtaining and maintaining stable fixation, both of which are necessary for healing to occur.

Search for Occult Fractures.

When the patient’s history or examination suggests a femoral neck fracture but radiograph findings are lacking, special evaluation is necessary. The initial study should be an AP pelvic radiograph, with the legs taped or held in gentle internal rotation. This should be carefully inspected for a femoral neck fracture. If a hip fracture is suggested from the history and physical findings but is not evident on this initial radiograph, it is important to obtain an AP radiograph of the symptomatic hip with the femur sufficiently internally rotated to show a maximal profile of the anteverted femoral neck region because this projection will be the most likely to demonstrate an occult fracture. In the absence of an obvious proximal femur fracture, this mandates further evaluation if the clinical setting is suspicious. High-quality CT scans with appropriately oriented reconstructions typically demonstrate a fracture, if even slight displacement is present. They may have been routinely obtained as part of the initial evaluation of a polytraumatized patient. An MRI, if the patient can tolerate it, has the advantages of demonstrating intraosseous swelling in acute undisplaced fractures as well as providing an immediate answer that expedites patient disposition and treatment. MRI is now the preferred imaging study to definitively evaluate for occult hip fracture. Iwata and associates reported that the T1-weighted coronal MRI scan showed a hip fracture with 100% sensitivity and is the best sequence to diagnose occult hip fracture ( Fig. 54-13 ). In the past, technetium-methylene diphosphonate (MDP) bone scans have been used to diagnose occult femoral neck fractures, but they often do not become positive for 2 to 3 days after injury in elderly patients.

A 65-year-old female who presented with pain in the left hip. A and B, Anterior-posterior (AP) and lateral image of the left hip does not show an identifiable hip fracture. C and D, T1-weighted coronal magnetic resonance imaging (MRI) scan showing a fracture line in the basicervical/intertrochanteric area. E, Short tau inversion recovery (STIR)-weighted coronal MRI showing bone marrow edema in the proximal femur area.

In the case of a high-energy injury, clinical suspicion for occult femoral neck fracture should be raised by an associated patellar fracture or knee ligament (especially posterior cruciate) injury, femoral shaft fracture, or an ipsilateral calcaneus, distal tibia, or tibial or femoral shaft fracture resulting from vehicular trauma or a jump or fall from a significant height. CT scans for screening for abdominal injury are often available and a few cuts of the femoral neck are generally available. If high-quality films of the hip do not reveal a femoral neck fracture and the associated injuries require urgent care, the physician should proceed with the urgent procedure. When treatment of other injuries is not pressing, the just-mentioned studies (i.e., CT or MRI) might be considered preoperatively. See later in the chapter for evaluation and management of ipsilateral femoral neck and femoral shaft fractures.

Computed Tomography.

CT and earlier tomographic techniques are helpful in identifying a nondisplaced femoral neck fracture when it is not radiographically apparent but is suspected on clinical grounds (e.g., history, complaint, or pain on rotation of the hip). CT may be particularly useful in a patient with a high-energy fracture who is undergoing an examination for abdominal, pelvic, or spine trauma. This technique is also of use in differentiating pathologic (nonosteoporotic) femoral neck fractures from nonpathologic fractures. Although good studies have confirmed that stability of the postfixation construct is most dependent on bone density, as yet, no clinical data derived from CT-measured density can be used to determine the potential for stability of internally fixed femoral neck fractures.

Radionuclide Studies.

Radionuclide uptake has been studied for more than 50 years in the hope that such techniques will detect AVN at an early stage. Historically, radioactive calcium, phosphorus, and iodine were injected and Geiger counter systems used to obtain data that could be assessed in terms of femoral head blood flow. Unfortunately, these studies were inconsistent, and involved high radiation burden for the patient.

The two techniques that remain in use for assessment of femoral neck fractures are sulfur colloid scans and technetium 99m ( ^99m Tc)-diphosphonate scans. The former is a compound that demonstrates bone marrow viability and has shown some success as a predictor of AVN. Unfortunately, a large series of patients has not been monitored following the use of this technique. It has been considered to be accurate, and the data obtained have been used to decide whether to perform prosthetic replacement. Compared with ^99m Tc-diphosphonate scanning, it has the drawbacks of a significantly higher radiation burden, less detailed images, and a longer delay after injection before the images are obtained.

^99m Tc-diphosphonate scanning is a method for obtaining predictive data in regard to the risk of nonunion and AVN. Stromqvist and coworkers published results from 468 patients who underwent serial bone scans after femoral neck fractures. They determined that visual evaluation of pictorial images (scintigrams) is neither reproducible nor reliable. However, quantitative scans (scintimetry) allow side-to-side digital comparison using carefully defined regions of interest. Recently, Kim and associates reported the role of preoperative bone scan to determine if the status of blood flow to the femoral head could be evaluated prior to surgery. This information was considered to be potentially useful to decide whether the patient should have an internal fixation or arthroplasty. They concluded that preoperative bone scan was not beneficial in determining treatment method. While preoperative bone scans were not predictive of AVN, such studies done 2 to 3 weeks after injury and fixation can identify patients likely to develop these problems. Data on femoral head uptake are expressed as a ratio relative to the intact side. If the ratio of the injured to the uninjured region of interest is less than 0.90, patients had an 84% chance of nonunion, AVN, or both. For patients with an abnormal contralateral hip, the uptake ratio of the femoral head to the ipsilateral femoral shaft can be measured. If this ratio is at least 0.40, uneventful healing is likely. By 4 weeks after injury, those in whom nonunion or AVN eventually develops have equal or higher femoral head uptake, which lasts up to 24 months after injury. These findings have been duplicated in animal models. These data integrate well with the hypothesis that revascularization follows an avascular episode and produces trabecular resorption and weakening, which allows mechanical failure in the subchondral plate and femoral head collapse.

Scintigraphic images (nonquantitative) produced by nuclear medicine scanning can be helpful for diagnosing occult problems of the proximal end of the femur. When plain radiographs are normal, osteoblastic activity in the region of the femoral neck, shown by a technetium-labeled phosphate scan, may indicate a nondisplaced or fatigue fracture. These changes may not appear until 72 hours after onset of symptoms. Scintigraphy can also help in searching for occult metastatic lesions, which might affect treatment plans for a pathologic fracture. These scintigraphic images are not, however, helpful for preoperatively establishing the prognosis of a given femoral neck fracture ( Fig. 54-14 ).

Scintigraphy after femoral neck fracture. A, A 23-year-old man fell off a bunk bed and sustained a displaced Garden grade III femoral neck fracture. B, The patient underwent a preoperative bone scan 8 hours after injury, with the right side showing lower femoral head uptake than the left. C, He underwent emergency open reduction using the Watson-Jones approach, with evacuation of intracapsular hematoma and screw fixation with four cancellous screws. D, A bone scan obtained the day after surgery shows an even lower amount of femoral head uptake than previously seen when compared with the normal side. E, At 3 weeks, a bone scan showed a high degree of uptake, greater than on the intact side. F, An 18-month follow-up radiograph showed the fracture to be united with no evidence of osteonecrosis. This result was confirmed at 10 years.

Dual-Photon Absorptiometry.

Dual-photon absorptiometry has been shown to provide an accurate determination of spinal osteoporosis. However, some published reports indicate that spinal bone density is not directly related to femoral neck bone density. The technique has been adapted to more accurately determine femoral neck bone density, and data regarding the bone density necessary to achieve stable internal fixation are available. Incorporation of hip axis length as an additional predictor of hip fracture risk is also feasible.

Magnetic Resonance Imaging.

MRI has been shown to be a sensitive indicator of avascular change within the femoral head in nontraumatic forms of AVN. The ability of MRI to detect acute femoral head vascular changes has been noted to be somewhat limited in clinical as well as in vivo laboratory studies. Severe distortion of the images is produced by proximal femoral internal fixation devices. Pure titanium or nearly pure titanium fixation devices must have been used if one wishes to obtain satisfactory femoral head MRIs after internal fixation; dark shadows remain on the images, but distortion is minimized. This technique may ultimately allow a greater understanding of the pathologic processes of posttraumatic AVN; however, it remains a tool that is unable to predict the patients in whom femoral head collapse will develop from posttraumatic osteonecrosis. It is the method of choice for detecting nondisplaced femoral neck fractures in patients with symptoms and normal radiographs because of the delay (up to 72 hours) in radionuclide uptake in fresh fractures and the suboptimal uptake of technetium-labeled phosphate compounds in the most elderly patients. MRI images can also help define the presence and extent of metastatic tumors involving the femur.

Ultrasonographic Venography.

High-resolution, real-time ultrasonography has attracted interest as a simple, repeatable, noninvasive means of diagnosing DVT. A variety of criteria have been proposed for the ultrasonographic diagnosis of venous thrombosis. In a prospective study of 40 patients with hip fractures, Froehlich and coworkers used a single test: noncompressibility of the vein lumen. This test was applied from the calf veins to the common femoral artery and validated by venography. Five patients (12.5%) had major thrombi; all were asymptomatic. Compression ultrasonography had an accuracy of 97%, a sensitivity of 100%, and a specificity of 97%. It is well tolerated and is significantly less expensive than venography, but it requires a well-trained technologist.

Nutritional Assessment.

Malnutrition is more common than what might be expected in elderly patients with hip fractures, even in those with adequate resources. Improved outcome after hip fracture has been demonstrated when dietary supplements are provided. Screening studies that may be used to evaluate nutritional status are the absolute lymphocyte count, serum albumin, transferrin, and skin fold thickness.

Essential Studies.

Diagnostic algorithms for patients with multiple injuries are presented in Chapter 9 . To prevent missing a femoral neck fracture (which occurs most frequently in midshaft femoral neck fractures), the femoral neck must be carefully scrutinized, as outlined previously. Spine and extremity radiographs are obtained in accordance with findings from the initial assessment, which includes a history of the injury and physical examination. A preoperative electrocardiogram, chest radiograph, complete blood cell count, urinalysis, and serum electrolyte, creatinine, and serum albumin studies should be obtained in all patients older than 40 years of age (see Chapter 53 ).

Nondisplaced Femoral Neck Fractures.

Nondisplaced fractures include both truly nondisplaced fractures and those impacted into a valgus position. Their absence of displacement is associated with lower risks of nonunion and AVN. However, the functional impact of these fractures remains significant. Biologically, their better prognosis results from the femoral head’s main arterial supply seldom (if ever) being disrupted with these fracture patterns. It may be, in these low-energy, undisplaced fractures, that intracapsular tamponade plays more of a role in producing AVN when it occurs.

Displaced Femoral Neck Fractures.

Displaced fractures include all femoral neck fractures with any detectable displacement. In the strictest sense, such displacement refers to any alignment offset (translation across the fracture plane) between the distal intertrochanteric fragment and the proximal femoral head fragment. This displacement is important for prognosis, because it correlates with damage to the major arterial supply to the femoral, and thus with risks of both AVN and nonunion. Additionally, when fracture management is delayed, synovial fluid may bathe the fracture surfaces, adding another impediment to fracture healing. The increased risk of AVN and nonunion after displaced femoral neck fractures should be considered when choosing treatment, and favor selection of arthroplasty, especially for older, more sedentary patients.

Fatigue Fractures of the Femoral Neck.

Fatigue fractures result from repetitive loading in pathologic (rheumatoid arthritis, osteoporosis) and nonpathologic (military recruits or repetitive trauma related to running) bone. Devas subclassified stress, or fatigue, fractures into two subgroups, transverse (tension) and compression, based on their appearance, in recognition of their different prognoses. It is important to recognize that fatigue fractures occur more often in patients with osteoporosis than in those with normal bone density. An association between stress fractures of the femoral neck and recent total knee replacement has been repeatedly identified. Stress fractures of the femoral neck are generally associated with decreased bone mineral density, even in younger patients.

Pathologic Femoral Neck Fracture.

Treatment of pathologic fractures, including those of the femoral neck, is covered in Chapter 20 .

Femoral Neck Fractures in Young Adults.

Treatment of fractures of the femoral neck in patients with open proximal femoral physes is beyond the scope of this text. (See Skeletal Trauma in Children , ed 5, Chapter 13 .) In adolescents and adults younger than 50 years of age, femoral neck fractures do occur as a result of high-velocity trauma in persons with normal bone density. The same classification (displaced vs. undisplaced) applies as noted previously, but the prognosis is worse in these younger patients. In these individuals, extreme trauma is required to produce displacement of the fracture fragments, which explains the increased incidence of AVN and nonunion in series of young patients. Smith documented loads of 900 to 2000 pounds to produce femoral neck fractures in cadavers. Assuming that these specimens were probably from older individuals, one can extrapolate that even higher forces are needed to fracture the femoral neck in young adults. It is encouraging to note that appropriate treatment with urgent, accurate reduction and internal fixation can result in preservation of the patient’s hip in 85% of patients at 10 years of follow-up.

Special Cases.

Certain conditions of abnormal bone metabolism significantly affect the diagnosis and treatment of femoral neck fractures. The following two conditions require individual consideration.

Basilar Neck Fracture.

Fractures that occur in the lower part of the femoral neck are often called basilar neck fractures. However, there is no precise definition for this term. These injuries occur through an area of transition. Although generally true, it cannot be universally stated that these fractures are extracapsular and carry a better prognosis. A severely displaced low femoral neck fracture can still disrupt the lateral epiphyseal artery complex. From laboratory studies, Claffey determined this degree of displacement to be half the diameter of the femoral head superiorly (distal fragment relative to the femoral head). Because diagnostic radiographs do not show the extreme of displacement that occurs at the time of the injury, arterial disruption is a distinct possibility in the case of a basilar neck fracture. Although most surgeons favor an internal fixation construct that would be selected for an intertrochanteric hip fracture, the fracture should be viewed biologically as a femoral neck fracture (with its attendant risk of AVN of the femoral head) and treated as such with urgent fixation and capsulotomy. As with more proximal fractures, stable fixation is advisable to promote fracture healing.

Current Algorithm for Treatment of Femoral Neck Fracture

Indications for Operative Intervention.

Surgical treatment is warranted for all but the most medically fragile and bedbound patients with displaced femoral neck fractures. Operative management has been shown to achieve significant functional benefit in cost-benefit analyses. The basic choice of treatment is between internal fixation and arthroplasty. This controversy is discussed in further detail later. It is recommended that several factors be considered when choosing treatment for patients with displaced femoral neck fractures.

Age alone is a poor predictor of activity level, bone quality, physiologic status, and life expectancy, all of which should also be considered when deciding between reduction and fixation and replacement arthroplasty. If successful, reduction (either closed or open) and internal fixation provide the best and most durable results. Failure is caused by early loss of fixation, by nonunion, or by symptomatic segmental collapse from AVN. Although not always predictable, fixation problems are most common in patients with osteopenic bone and comminution. Prosthetic replacement of the proximal part of the femur avoids the problems of nonunion and AVN but may be associated with higher perioperative morbidity than seen with internal fixation. In addition, arthroplasty poses late problems of loosening and acetabular erosion, either of which may require revision surgery. Results after revision of failed hemiarthroplasties are not as good as those after primary THA, and the procedure may be quite difficult. Therefore, initial treatment of a displaced femoral neck fracture should seek to minimize the likelihood of future revision for failed arthroplasty. It appears that this is best accomplished by restricting hemiarthroplasties to low-demand users with limited life spans. Improvement in implant design may increase their durability and ease of revision, although the data to support this assertion remain inconclusive.

Factors that suggest the advisability of prosthetic replacement include pathologic bone, severe chronic illness (especially rheumatoid arthritis, osteoarthritis, or chronic renal failure), and a significantly limited life span. Advanced chronologic age alone is a questionable indication for hemiarthroplasty. The average life expectancy for 75-year-olds is more than 10 years. Therefore, many orthopaedists would extend the indications for internal fixation into the early and mid-70s for active individuals with good bone density and no chronic illness. Inactive, osteoporotic elderly patients with a limited life span are candidates for simple unipolar hemiarthroplasties. Those with displaced femoral neck fractures who can ambulate functionally outside their homes (community ambulators) and whose likelihood of success with internal fixation is low should be considered candidates for hip arthroplasty, either total hip replacement or hemiarthroplasty, the latter generally being reserved for less active patients.

Controversial Topics

Timing of Surgery.

There is no consensus for advocating or delaying surgery for femoral neck fractures. Proponents of early surgery would suggest that prompt reduction of displaced femoral neck fractures will unkink the vessels and allow intracapsular decompression to remove the offending agent of increased intracapsular pressure Restoring the anatomy will improve blood flow to the femoral head, thus minimizing the risk of femoral head osteonecrosis. Swiontkowski and associates recommended that treatment of femoral neck fractures should be performed within 8 hours after injury. Subsequent studies also suggested that early surgery (within 6 to 12 hours) can decrease the rate of femoral head osteonecrosis.

Jain and associates published a series of 38 patients with subcapital hip fractures in a comparative cohort design. They compared early (<12 hours) and delayed (>12 hours) surgical fixation. Their results showed radiographic evidence of femoral head AVN in 16% of the patients (all in the delayed fixation group). There were no differences in the rate of AVN with regard to age, fracture displacement, and method of fracture fixation. Functional outcomes were collected and they did not find a difference in the functional results between the patients that developed osteonecrosis and the patients that did not have osteonecrosis. Delayed treatment had an increased rate of osteonecrosis, but did not affect the functional outcomes.

Subsequent studies published did not show any differences in the rate of osteonecrosis with delayed surgery greater than 24 hours. Upadhyay and associates reported a prospective, randomized study comparing ORIF and closed reduction and percutaneous pinning (CRIF) in young adults with displaced femoral neck fractures. Forty-four femoral neck fractures were randomized to the ORIF (a Watson-Jones approach with a T-shape incision in the capsules) and 48 femoral neck fractures were randomized to the CRIF. The majority of the patients were treated more than 48 hours after injury, however, which likely dampened the impact of the open reduction. The result showed no difference in the rate of osteonecrosis between the two groups (14.6% for the CRIF and 18.2% for the ORIF). They evaluated other risk factors (age, gender, time to surgery [<48 or >48 hours], and posterior comminution) and there was no correlation with the development of osteonecrosis.

Delay from fracture to hospital admission significantly increases the risk of mortality. Many older patients with femoral neck fractures have significant medical problems, which increase the risk of mortality. Correcting these problems preoperatively may greatly reduce the risk of complications. Therefore, extreme care should be taken to optimize the patient’s condition for surgery (see Chapter 53 ). Delay to surgery for “systems failures” (i.e., lack of operating room availability) should, however, be avoided. One risk-adjusted analysis did not reveal an increased association between mortality and delay to surgery. However, Zuckerman and colleagues showed increased mortality in patients with two or fewer comorbidities in whom surgery had been delayed for more than 2 calendar days. Parker and Pryor confirmed the increased morbidity in patients who have no comorbidities but in whom surgery is delayed. Similarly, Rogers and associates documented a significant increase in mortality in physiologically stable elderly patients with isolated proximal femoral fractures and a delay of more than 24 hours before surgery. Early surgery was not associated with improved function or mortality in one recent prospective chart study. Delay longer than it takes to stabilize patients medically is not advised.

In summary, young patients with femoral neck fractures should have the surgery performed on an urgent basis. Femoral neck fractures in young adults are often caused by high-energy injuries and may have other associated injuries. As soon as the patient is considered medically stable and cleared to undergo anesthesia, ORIF of the femoral neck should be done. As for the elderly patients with multiple medical conditions, it is best to optimize them medically before proceeding with surgical intervention. However, surgery should not be delayed more than 2 days. This may require careful coordination and communication among the patient’s health care providers (orthopaedic surgeon, hospitalist, anesthesiologist, nurse, and patient and/or family members).

Fixation Methods.

Historically, more than 100 different internal fixation devices have been used for stabilizing femoral neck fractures. Triflanged nails, either with or without femoral shaft side plates, should not be used to internally fix femoral neck fractures. The distraction produced when using these devices has been shown to have an adverse effect on femoral head blood flow. The device chosen should have a mechanism for producing compression across the fracture site.

The recommended implant(s) for internal fixation of a femoral neck fracture are multiple pins or some type of cannulated or noncannulated cancellous screw. Screw cannulation allows the use of guide wires, thereby enabling the use of guide systems to help achieve parallel placement of the implants. In general, the amount of compression generated across the fracture is proportional to the thread area of the screw. The critical element in fracture stability is the density of the bone. The use of more than three implants does not seem to provide any increased mechanical advantage. Washers do add to the stability of fixation.

Brodetti has shown that large implants, if placed suboptimally in the posterior or superior aspect of the femoral head, can damage the blood supply to the femoral head. However, Ort and Lamont have reported results with compression screws that are equal to those of other techniques, and Bonnaire and associates reported that their results (in terms of osteonecrosis) were better with sliding hip screws. If this device is selected, a second pin or screw should be inserted superior to the guide wire for the large compression screw, to control rotation of the femoral head fragment. Because the hip compression screw by itself controls rotation poorly when compared with implants with multiple screws or pins, this superior screw should remain as part of the definitive fixation. Hernefalk and Messner demonstrated increased stiffness of implants with side plates. Malposition of the screw within the femoral head in patients with a femoral neck fracture has been shown to be more common in patients with left hip fractures when the surgeon is right hand dominant.

Recently, there are multiple biomechanical and clinical studies evaluating the different fixation methods for femoral neck fractures. For the majority of femoral neck fractures, fixation with multiple cancellous lag screws is recommended. Ideally, the screws are placed parallel to each other and perpendicular to the fracture line to obtain optimal compression at the fracture. Femoral neck fracture that are more transverse or horizontal (Pauwels type I and II fractures) are most amenable to this type of fixation. These three cancellous lag screws should be in an inverted triangle configuration. This apex-distal screw orientation has less risk of producing a subtrochanteric fracture when compared to the apex-proximal orientation. The distal screw should be placed along the medial femoral neck to resist varus displacement. The use of a fourth screw may be beneficial in femoral neck fractures where there is posterior comminution. However, a fourth screw does not increase in mechanical strength enough in most femoral neck fractures to justify its use. Two cannulated screws are inadequate fixation for a displaced femoral neck fracture.

The sliding hip screw (SHS) is another good implant of choice, especially for basicervical femoral neck fractures with comminution. SHS has been shown to provide more stable fixation than three cancellous screws for basicervical femoral neck fracture patterns. Blair and associates published a biomechanical cadaver study evaluating three different fixation techniques for treatment of basicervical femoral neck fracture. They recommend the SHS implant for this fracture pattern. Moreover, they suggested that a derotation screw located superior to SHS did not add any increase in fixation after the SHS is placed. However, a derotational screw can be beneficial to prevent rotation of the femoral head during insertion of the compression screw.

The femoral neck fracture with a more vertically oriented fracture pattern (Pauwels type III) can be very challenging to obtain and maintain reduction. This high-angle fracture pattern is associated with higher rates of failure and nonunion. The key to successfully treating this high-angle fracture pattern with three cancellous screws is obtaining an anatomic reduction and placing the screws strategically. This is best accomplished through an open approach to visualize the fracture, anatomic reduction of the fracture, and fracture compression with three screws, optimally placed in parallel. The first screw should be placed inferior along medial femoral neck on the AP imaging and centered on femoral neck in the lateral imaging. The second should be placed superiorly on the AP imaging and anterior along the neck in the lateral imaging. The third screw should be placed superiorly on the AP imaging and posterior along the neck in the lateral imaging. A good spread, if not divergent, placement of the three screws on the lateral view is important ( Fig. 54-17 ). This will help maintain the reduction and decrease the risk for nonunion.

A, A 59-year-old male fell off a bicycle and sustained a Garden type II femoral neck fracture. B and C, Intraoperative imaging shows the first screw should be placed inferior along medial femoral neck on the anterior-posterior (AP) view and centered on the femoral neck in the lateral imaging. D and E, The second should be placed superiorly on the AP imaging and anterior along the neck in the lateral imaging. F and G, The third screw should be placed superiorly on the AP imaging and posterior along the neck in the lateral imaging. H and I, A good spread, if not divergent, placement of the three screws on the lateral view is important

A SHS is another good option for Pauwels type III femoral neck fractures ( Fig. 54-18 ). Baitner and associates compared SHS with three cannulated cancellous screws for the Pauwels type III fractures. They concluded that fixation with SHS resulted in less inferior femoral head displacement, less shearing displacement, and a greater load to failure. Bonnaire and Weber evaluated four different methods of fixation for Pauwels type III fractures using a cadaveric model. They compared SHS with a derotational screw, SHS without derotational screw, cancellous screws, and a 130-degree blade plate. Their results showed that SHS with the derotational screw is the best implant for this fracture pattern. However, there are disadvantages to using these large compression hip screws. There are concerns for the amount of bone loss if subsequent reconstruction is required for nonunion, the risk of disrupting blood supply to the femoral head if imperfectly placed (particularly posterior-superior position), and their inability to adequately control rotation without inserting an additional derotational screw.

Pauwels type III femoral neck fracture treated with a sliding hip screw. A, A 49-year-old male cyclist collided with other cyclists and sustained a high angle femoral neck fracture. B, At 3 years’ follow-up, he has a healed femoral neck fracture without osteonecrosis.

Fixation of femoral neck fracture with multiple cancellous screws allows for excellent compression but does not provide length stability. Zlowodzki and associates reported a shortening rate of 31% for undisplaced and 27% for displaced femoral neck fractures. Femoral neck shortening does have a negative effect on the functional capacity and quality of life. Aminian and associates evaluated the biomechanical stability of the fixed-angle proximal femoral locking plate (PFLP), the 7.3-mm cannulated screws, the 135-degree dynamic hip screw (DHS), and the 95-degree dynamic condylar screw (DCS) for fixation of femoral neck fractures. Using cadaveric femurs and creating a Pauwels type III fracture, they found that the strongest construct was the PFLP. This is followed by DCS, DHS, and the three-cannulated-screw construct. One of the advantages of the PFLP is that it allows for multiple fixed-angle points of fixation into the femoral head. The major disadvantage is that proper anatomic reduction and compression of the fracture is necessary prior to fixation, as the PFLP does not allow for fracture compression. Boraiah and associates published their series of 54 femoral neck fractures that were treated with length-stable implants after intraoperative fracture site compression. Fifty-one (94%) patients healed their femoral neck fracture with minimal shortening. In contrast, Berkes and associates reported their clinical series of 18 patients who were treated with posterolateral femoral locking plate (PLFLP). The purpose of using the locking plate construct was to provide length-stable rigid fixation and prevent femoral neck collapse and shortening. The result of this study showed a poor outcome with failure in seven patients. The authors suggested that the construct was too stiff to allow for small fracture site micromotion that would encourage bony union. Most of the failures occurred with screw breakage and resulted in varus collapse. There is insufficient clinical experience with the PFLP to recommend its routine use.

Role of Capsulotomy.

Intracapsular tamponade has similarly been found to have a negative influence on femoral head blood flow in numerous laboratory and clinical studies. Performing an anterior hip capsulotomy at the time of surgical fixation remains controversial. There are both animal and clinical studies that support the role of capsulotomy. Animal studies have shown reduced blood flow to the femoral head when there is an increase in intracapsular hip pressure. Multiple clinical studies have evaluated the impact of increased intracapsular pressure in nondisplaced femoral neck fractures. Even nondisplaced femoral neck fractures can have intracapsular hip pressure that exceed the normal hip pressure. Reducing the hip pressure can be done with hip aspiration or better with open or percutaneous capsulotomy. The theoretical advantage of decreasing the intracapsular pressure will lead to improved blood flow to the femoral head. Removal of this tamponade effect may reduce femoral head ischemia and ultimately decrease the risk of femoral head AVN. There are recent clinical series that showed AVN occurred even in the nondisplaced femoral neck fractures. It is difficult to conceive of a mechanism for posttraumatic femoral head osteonecrosis apart from intracapsular tamponade in a nondisplaced fracture. Moreover, a recent study by Papakakis and associates showed that the posterior retinaculum of the hip remains intact in most displaced femoral neck fractures. They prospectively evaluated 112 patients with Garden type III and IV femoral neck fractures that underwent hemiarthroplasty. Intraoperatively, the anterior and posterior retinacula of the hip were inspected for tears. They found that the posterior retinaculum was intact in all Garden type III and in 95.2% of completely displaced femoral neck fractures. This study advocated the benefit of performing an anterior capsulotomy for displaced femoral neck fracture treated with internal fixation.

Although some authors disagree, the current recommendation is to extend the standard lateral approach into the Watson-Jones interval between the tensor fasciae latae and gluteus medius and perform an anterior capsulotomy under direct vision ( Fig. 54-19 ). Although possibly only 5% to 15% of fractures are seen in which the hip capsule is not disrupted and sufficient intracapsular pressure has accumulated to impede venous drainage or arteriolar supply of the femoral head, these fractures can be effectively treated by this simple maneuver. Capsulotomy adds 5 to 10 minutes to the dissection and exposes the patient to no further risk. There are no published reports of complications with performing an open anterior capsulotomy (directly visualizing the capsule and performing a capsulotomy). However, detachment of the scalpel blade from the knife handle during a percutaneous capsulotomy has been reported ( Fig. 54-20 ). After successful closed reduction and stable fixation of the femoral neck, we recommend performing a percutaneous capsulotomy with a No. 10 or 15 blade ( Fig. 54-21 ). To avoid detachment of the blade, the surgeon should make sure the blade is fully seated on the knife handle and can wrap the blade and the handle with a narrow strip of Ioban (3M, St. Paul, MN). The blade is slid over the anterior trochanter and in line with the center of femoral neck on AP C-arm images. Lateral C-arm images should be obtained and the capsulotomy should be performed in the lateral view (making sure you are right on top of the femoral neck bone by feel and by C-arm images). If there is a mini-incision made to place the implants, then a flash of hematoma should be seen to ooze out when the capsulotomy is complete. Furthermore, anatomic reduction can then be achieved under direct vision. In delayed treatment of displaced femoral neck fractures, open reduction does not favorably impact the rate of AVN.

The Watson-Jones anterolateral exposure to the hip for open reduction of femoral neck fractures. The interval between the tensor fasciae latae and the abductors is bluntly developed, and the vastus lateralis is elevated off the intertrochanteric ridge. The capsule is divided anteriorly along the axis of the neck of the femur and transversely released from its insertion into the proximal part of the femur. With sutures as retracting aids, the fracture can be visualized. A bone hook can be used to disimpact the fracture by applying a laterally directed force, and a blunt instrument can be inserted to improve the reduction (i.e., lift the proximal fragment anteriorly). The insertion area for internal fixation devices on the lateral aspect of the proximal end of the femur is easily exposed.

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