Management of Neck of Femur Fractures

Classification and Initial Assessment

• Neck of femur fractures are classified as either intracapsular or extracapsular, with intracapsular fractures having minimal blood loss due to poor vascular supply and capsular tamponade, whereas extracapsular fractures may have significant blood loss, according to the American Academy of Orthopaedic Surgeons 1, 2
• Extracapsular fractures are generally more painful than intracapsular fractures due to greater periosteal disruption, as noted by the American Academy of Orthopaedic Surgeons 2
• Surgery should be performed within 24-48 hours of admission for better outcomes, as recommended by the American Academy of Orthopaedic Surgeons 3

Surgical Management by Fracture Type

• For unstable/displaced intracapsular fractures, arthroplasty is strongly recommended over internal fixation, with total hip arthroplasty (THA) preferred for healthy, active, independent older individuals without cognitive dysfunction, and hemiarthroplasty preferred for frail patients, according to the American Academy of Orthopaedic Surgeons and the American College of Rheumatology 4, 5, 6, 7
• For intertrochanteric fractures, stable fractures can be treated with either sliding hip screw or cephalomedullary device, while unstable fractures require antegrade cephalomedullary nail, as recommended by the American Academy of Orthopaedic Surgeons and the American College of Rheumatology 4, 5, 6, 7
• For subtrochanteric/reverse obliquity fractures, cephalomedullary device is strongly recommended, according to the American Academy of Orthopaedic Surgeons and the American College of Rheumatology 4, 5, 6

Perioperative Considerations

• Either spinal or general anesthesia is appropriate for surgery, with some evidence suggesting regional anesthesia may reduce postoperative confusion, as noted by the American Academy of Orthopaedic Surgeons and the American Society of Anesthesiologists 4, 3, 1, 2
• Cemented femoral stems are strongly recommended for arthroplasty, as they improve hip function and reduce residual pain, according to the American Academy of Orthopaedic Surgeons 8, 9, 4, 10

Postoperative Management

• Multimodal analgesia incorporating preoperative nerve block is strongly recommended for pain control, according to the American Academy of Orthopaedic Surgeons 8, 9, 4
• Tranexamic acid should be administered to reduce blood loss and blood transfusion requirements, as recommended by the American Academy of Orthopaedic Surgeons 8, 9, 4
• Interdisciplinary care programs should be used to decrease complications and improve outcomes, with postoperative care including appropriate pain management, antibiotic prophylaxis, correction of anemia, cognitive function assessment, pressure sore prevention, nutritional support, and early mobilization, according to the American Academy of Orthopaedic Surgeons and the American College of Rheumatology 8, 9, 4, 6, 7
• Venous thromboembolism prophylaxis is strongly recommended, as noted by the American Academy of Orthopaedic Surgeons 10

Surgical Considerations for Femoral Neck Fractures

Patient Selection and Outcomes

• The American Academy of Orthopaedic Surgeons acknowledges that improved function with THA comes at the risk of increased complications, which is why the recommendation was downgraded from strong to moderate despite strong evidence for functional benefit 11, 12
• Cemented femoral stems are strongly recommended to improve hip function, reduce residual pain, and decrease periprosthetic fracture risk 11, 12
• For hemiarthroplasty, unipolar or bipolar designs are equally beneficial 12
• THA has increased surgical time and blood loss compared to hemiarthroplasty 11
• Uncemented stems should not be used in elderly hip fracture patients due to increased periprosthetic fracture risk 11

Management of Femoral Neck Fractures in the Elderly

Treatment Recommendations

• For unstable (displaced) femoral neck fractures in elderly patients, arthroplasty is the definitive treatment, and this decision should be made immediately upon diagnosis, as recommended by the American Academy of Orthopaedic Surgeons 13
• The American Academy of Orthopaedic Surgeons recommends that for healthy, active, independent elderly patients without cognitive dysfunction, total hip arthroplasty provides superior functional outcomes despite increased complication risk 13
• Cemented femoral stems are strongly recommended for all elderly hip fracture patients undergoing arthroplasty, as they improve hip function, reduce residual pain, and decrease periprosthetic fracture risk, according to the American Academy of Orthopaedic Surgeons 13
• Either spinal or general anesthesia is appropriate for elderly patients undergoing arthroplasty for femoral neck fractures, as stated by the American Academy of Orthopaedic Surgeons 13
• Administering tranexamic acid at the start of surgery can reduce blood loss and transfusion requirements in elderly patients undergoing arthroplasty for femoral neck fractures, as recommended by the American Academy of Orthopaedic Surgeons 13
• The American Academy of Orthopaedic Surgeons recommends against using internal fixation for displaced fractures in elderly patients, as arthroplasty provides superior outcomes 13
• Multimodal analgesia should be continued postoperatively for elderly patients undergoing arthroplasty for femoral neck fractures, as recommended by the American Academy of Orthopaedic Surgeons 13
• Administering multimodal analgesia with preoperative nerve block is recommended for elderly patients undergoing arthroplasty for femoral neck fractures, as stated by the American Academy of Orthopaedic Surgeons 13