On the diagnosis and treatment of femoral neck fractures

Figures & data

Figure 1. The hip joint and the proximal femur. Reprinted with permission from the BMJ.[1]

Text box 1. Signs and symptoms of a hip fracture

Shortening and external rotation of affected leg

Inability to bear weight on affected leg

Inability to move affected leg

Pain on passive movement

Groin pain

Pain on palpation of trochanter major

Inability to raise leg straight while supine

(sensitive sign in less obvious cases)

Text box 2. Different hip fractures and their treatment

Fracture	Recommended treatment	Good alternative (e.g. for some fractures/ some patients)	Probably inferior alternative(s) in most cases
Undisplaced femoral neck fracture[6];[7]	Internal fixation with parallel screws	Hemiarthroplasty or total hip arthroplasty	Sliding screw/plate device
Displaced femoral neck fracture[5];[8];[9]	Hemiarthroplasty	Total hip arthroplasty	Internal fixation
Trochanteric fractures[4];[10-12]	Sliding screw/plate device		Intramedullary nail
Subtrochanteric fractures[4]	Intramedullary nail	Sliding screw/plate device

Text box 3. Choices of internal fixation or arthroplasty[9]

Method	Potential problem/advantage
Arthroplasty[41]
Hemiarthroplasty or total hip arthroplasty	Higher dislocation rates in total hip arthroplasty. Total hip arthroplasty may give better function in the healthiest patients.[9];[42],[43] Total hip arthroplasty is more extensive surgery.
Cemented or uncemented arthroplasty[44]	Cemented arthroplasty may give faster rehabilitation, especially when compared to non-anatomical uncemented arthroplasties.[41] Acute cement toxicity may be fatal.[45] Cemented arthroplasty may be more difficult to remove if needed.
Bipolar or unipolar hemiarthroplasty	Bipolar may give better range of motion, and less acetabular wear, but more potential for dislocations as the device is more complicated.[46]
Internal fixation[47]
Sliding screw with plate, or screws or nails	Sliding screw with plate gives more wound problems, but may be more stable.[48];[49] Screws may be more stable than nails.[50]
Two or more screws or nails	More than two screws may increase stability, but take longer to insert and may invite complications.[47];[51]

Figure 2. Garden's classification. Garden stages 1–4. Reproduced with permission and copyright © of the British Editorial Society of Bone and Joint Surgery [80];[85]

Figure 3. Anterioposterior pelvic radiograph of a patient who has suffered femoral neck fractures on both sides, only a few weeks apart. On the right side she was operated with two parallel screws and on the left side with a hemiarthroplasty.

Figure 4. Example of screw voids in the femoral head after reversing the screws. The whiter appearance of the bone on the right hand side of the femoral head indicates that the bone density is higher in the femoral head near the joint space than it is towards the femoral neck. The better screw purchase provided by this bone is one of the reasons that the recommended screw placement is as near to the joint line as possible. The screws are only partially threaded to allow for compression over the fracture.

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