These have little or no displacement of the fracture and usually very little risk for vascular damage to the femoral head and thereby little healing complications. This group of cervical fractures contains the Garden groups I and II [12]. Primary operation with osteosynthesis is advocated all over the world. The most used methods are either two or more parallel screws or two hook pins. The screws mostly differ by modifications of the configuration of the screwing in the top part [11, 17]. A few centres have tried not to operate some undisplaced fractures [18]. This leads to increased risks of dislocation and thereby a prognostic deterioration for the healing. Non-operative treatment also demands non-weight bearing and increased check-ups, both clinically and with radiography. It is a much safer method to operate the fracture and allow the patient full immediate weight bearing [19].

These fractures have been the area of continuous disagreement for the last half century. Slowly more agreement is reached. There is a geographical difference internationally concerning the treatment principles for the displaced cervical fractures. In Scandinavia, particularly in Sweden and Norway, primary osteosynthesis has been performed in all cases with displaced cervical fractures. The basic philosophy has been to perform a small, quick and for the patient less burdening operation first and in the case of a healing complication later as a secondary procedure do a well-planned arthoplasty. This is usually then performed as a total hip arthroplasty where both the femoral and the acetabular parts are exchanged. It is an undisputed fact that the best long-term result after a femoral neck fracture is a healed fracture and preservation of the patient’s own femoral head provided no segmental collapse appears. This will give no future problems. An arthroplasty always has the risk of dislocation in the short time perspective and in the long run the risk of loosening and for the hemi-arthroplasties also by the years deterioration of the acetabular cartilage. When a patient has been operated with an osteosynthesis and 2 years has passed since the fracture and this is healed without complications, there is little risk of further problems from this hip [11, 20]. Some patients however never regain the full functional level that they had before the fracture. The complications after an arthroplasty increase after 5–10 years and this risk has to be balanced against the expected remaining lifetime for the patient [21]. Therefore arthroplasty is used mainly in elderly patients with clearly displaced fractures.

Internationally in many western countries the primary choice for a displaced femoral neck fracture is to perform an arthroplasty. This basic principle has been to treat all patients with arthroplasty to avoid healing complications in some. The treatment philosophy is now modified and an increasing amount of primary osteosyntheses is performed above all in relatively younger patients and those with less severe dislocation. Many studies have shown somewhat increased mortality after primary arthroplasty compared to primary osteosynthesis [11, 21, 22]. At the same time studies have shown a higher need of re-operation after the primary osteosynthesis within the first 2 years after the fracture compared to after a primary arthroplasty. The complications after a primary arthroplasty develop later and also a re-arthroplasty is a bigger operation and has more inherited complications than a secondary arthroplasty after a failed primary osteosynthesis [17].

The international literature shows that healing problems due to vascular damage of the femoral head by the displaced cervical fracture leads to non-union in 10–30 % of the cases and segmental collapse in further 10–20 % of cases. With an optimised osteosynthesis technique the healing complications (both non-union and segmental collapse) has been limited to in total 20–25 % for the displaced cervical fractures [20, 23].

Primary arthroplasty results in dislocation in around 4 % of the cases with hemi-arthroplasty and in 10 % with total hip arthroplasty. Infection consists of 2–5 %. Following a hemi-arthroplasty around 20 % of the cases in the long run develop wear and deterioration of the acetabular cartilage. Loosening is expected in around 10 % of the cases. Fracture in connection with the arthroplasty amount to 2–4 %. Re-operation with arthroplasty after a primary osteosynthesis has been reported to 20–30 % of the displaced cervical fractures. A major re-operation within the first years after a primary arthroplasty is expected to be needed in around 10 % of the cases. These are then rather complicated operations [11, 17, 21].

Unipolar hemiarthroplasty or a total hip replacement give better functional results within the first 2 years than a primary osteosynthesis. A total hip arthroplasty or a bipolar hemiarthroplasty probably gives better functional results after 2 years than a unipolar hemiarthroplasty. Cemented stem gives better outcome than uncemented. Uncemented cup is not recommended to these osteoporotic patients [11, 16].

Randomised studies have been performed both in Sweden and abroad to improve the criteria for the choice between a primary osteosynthesis and a primary arthroplasty [24–27]. Most of these studies have shown relatively high number of complications for osteosynthesis when compared with previously published consecutive series during the last decades [20, 23]. A differentiated treatment protocol results in fewer re-operations [15, 16, 28–30].

Based on the results of these randomised studies the treatment policy in Sweden has changed during the last decade so the most displaced fractures in elderly patients now in increasing amount receive a primary arthroplasty. A primary arthroplasty is advocated if the cervical fracture is clearly displaced with lack of continuity both on the frontal and the side view, particularly in patients with high degree of osteoporosis. Also the patient should have been walking prior to the fracture. The age should be above 70–75 years, where biological age is more important than chronological. Irrespective of the patient’s age the primary arthroplasty is recommended in cases with disease to the hip joint such as rheumatoid arthritis or a pathological fracture secondary to malignancy or other destruction of the hip joint; e.g. after infection. Also a lately diagnosed fracture is indicated for arthroplasty, particularly if the scintimetry has shown a low uptake. Arthrosis in the fractured hip joint is also an indication for primary arthroplasty. The primary arthroplasty is however not recommended in patients with severe dementia, bedridden patients or patients with bad muscular function due to the increased risk of dislocation.

The tendency internationally now aims at a differentiated treatment protocol according to the principles given above. In waiting for better diagnostic possibilities of the circulation to the femoral head, the principles indicated will probably result in that two thirds of the displaced cervical fractures will be operated with primary osteosynthesis and the other third with a primary arthroplasty, then preferably a bipolar with cemented stem.

Hip fracture patients should be operated as soon as practically possible. Directly life threatening conditions must of course have priority before the hip fractures, but these elderly patients will have a prolonged rehabilitation and functional less optimal result if the time between arrival to hospital and operation is unnecessarily delayed. This in turn leads to more complications and inactivity in these elderly persons. It can also generate increased nursing needs with great economic consequences. The goal is to operate the patient on the day of arrival and at latest within 24 h. If the patient is operated with osteosynthesis within 6 h from the fracture it has been shown that the risk for blood circulation disturbance to the femoral head and thereby following healing complications diminish [31].

Apart from being strenuous for the patient due to pain and immobilisation a delay of the operation is associated with increased morbidity and mortality. A delay of more than 24 h between arrival to hospital and osteosynthesis of the fracture has shown association to increased mortality. Lower mortality has been shown when the operation was performed within 12 h. If a delay is unavoidable the time should be used to improve the general condition of the patient, particularly the fluid balance [16, 17, 21].

Osteosynthesis for cervical fractures is performed with the use of a fracture table allowing traction under the image intensifier. Preferably a biplanar image intensifier is used. It is wise to supervise the transferring of the patient to the fracture table, as the injured leg has to be treated with great care to prevent fracture displacement occurring or damage to the retinacular vessels. A manual traction on the leg straightening it out during transfer is advisable. Also to reduce the risk of pressure sores padding should be applied to any area of pressure such as around the feet, sacrum and groin. The uninjured leg should be flexed and abducted as much as possible. Positioning of the image intensifier is easier if the hip and knee are flexed to 90° on the uninjured side (Fig. 38.1). A displaced cervical fracture is reduced by longitudinal traction followed by inward rotation. A biplanar image intensifier has the advantage that after positioning of the equipment no further movements of the stand or tube are necessary, which thereby avoids jeopardising the draping and thereby the sterility. The shifting between the views is done on the monitor with a foot pedal, which considerably saves operation time. Also the easy rapid shifting between the positions increases the precision in the positioning of the osteosynthesis material. The importance for the circulation to the femoral head of a low traumatic operating technique has been proven [32]. The channel should be pre-drilled and hammering in of osteosynthesis material avoided. Also impaction of the fracture by hammering increases the damage of the circulation to the femoral head. The best way to achieve compression in the fracture is by the patient’s own muscle forces at weight bearing. For undisplaced fractures early surgery will allow aspiration of any haematoma within the joint capsule. This may reduce the risk of avascular necrosis caused by ischaemia from a tamponade effect on the intracapsular vessels. Cervical fractures are operated with parallel pins or screws to allow axial compression along the axis of the femoral neck perpendicular to the fracture line when the patient is weight bearing. This is a physiological way of compressing the fracture. To prevent slipping out of the osteosynthesis material they are either threaded as screws or have a hook that can be pressed out through a central canal. To facilitate parallel positioning most devices are cannulated and have instruments to enable parallel placement. The most commonly used methods of fixation are two or three parallel cancellous screws, two parallel hook pins or a dynamic hip screw. The blood circulation to the femoral head via the capsule vessels along the femoral neck is vulnerable. Sudden forceful movements of the hip during reduction or excessive traction causing fracture diastasis may damage the femoral head circulation. The fracture is usually reduced by applying traction to the outstretched leg, followed by internal rotation. These manoeuvres should be checked throughout the procedure in both the lateral and the anterior-posterior radiograph using the image intensifier which should have a large field of view and a good resolution facility. The reduction manoeuvre is begun by using the fracture table to apply gentle traction to the leg, progressively while checking in the AP radiograph. Traction is applied until the medial parts of the femoral neck, the calcar region, are approximated with anatomical contact between the bone ends. Next, the lateral view is obtained and the foot is rotated inwards until the dorsal angulation of the femoral neck fracture has been counteracted. This part of the manoeuvre can be likened to closing an open book. The aim is to restore the alignment of the femoral neck such that a straight line can be drawn to bisect the femoral head, trochanteric region and shaft. It is essential that there is no residual fracture angulation, as this will increase the risk of re-displacement of the fracture. Quite frequently there is need to apply more than 90° of inward rotation to achieve reduction. Small corrections with ab-adduction and sometimes elevation of the leg may also be needed to obtain an anatomical reduction. Following the reduction maneuver it is advisable to slacken the traction somewhat. This allows some impaction to occur at the fracture site and reduces the risk of the femoral head rotating during drilling.