Management of Neglected Femoral Neck Fracture in Elderly Patients

Clinical Presentation and Examination Findings

The American Academy of Orthopaedic Surgeons notes that a neglected femoral neck fracture typically presents with a shortened and externally rotated limb, the classic deformity seen with displaced intracapsular fractures 3
Elderly patients with neglected femoral neck fractures often experience severe pain with attempted weight-bearing or hip movement, though some patients with minimally displaced fractures may retain limited ambulation ability 4
Groin pain radiating to the knee, with tenderness over the anterior hip capsule, is a common symptom 1
Limited range of motion in all planes, particularly internal rotation and flexion, is typically observed 3
Possible skin changes or redness suggesting prolonged immobility, pressure effects, or inflammatory response requiring immediate evaluation 4
Leg length discrepancy with the affected limb appearing shorter is a common finding 1

The American Academy of Orthopaedic Surgeons recommends obtaining AP pelvis and lateral hip radiographs to confirm fracture displacement and chronicity 3, 4
A complete blood count is necessary to assess for anemia and infection 4
A basic metabolic panel is required to evaluate renal function, electrolytes, and glucose control 3, 4

The American College of Surgeons strongly recommends arthroplasty over internal fixation for displaced femoral neck fractures in elderly patients 1, 2
Hemiarthroplasty is preferred for frail patients with multiple comorbidities, patients with cognitive dysfunction or dementia, limited pre-injury mobility, and higher surgical risk profile 1, 2
Total hip arthroplasty is preferred for healthy, active, independent patients without cognitive dysfunction, pre-existing hip osteoarthritis, and higher functional demands 1, 2, 3
The use of cemented femoral stems is strongly recommended to improve hip function, reduce residual pain, and decrease periprosthetic fracture risk in osteoporotic elderly patients 1, 2, 4

The American Society of Anesthesiologists notes that either spinal or general anesthesia is appropriate for surgery 3, 1, 4
Administering tranexamic acid at surgery start reduces blood loss and transfusion requirements 1, 2, 4
Multimodal analgesia with preoperative nerve block is recommended for optimal pain control 1, 4
Surgery within 24-48 hours of admission significantly improves outcomes and reduces mortality 1, 2, 4

The American Academy of Orthopaedic Surgeons recommends immediate weight-bearing as tolerated after surgery 3, 4
VTE prophylaxis for 4 weeks postoperatively with enoxaparin, fondaparinux, or equivalent is strongly recommended 1, 2, 4
Interdisciplinary care with orthogeriatric comanagement is necessary to manage multiple comorbidities and decrease complications 1, 2, 4
Early mobilization reduces DVT risk and improves functional recovery 2
Structured geriatric rehabilitation prevents functional decline 2
Referral to Fracture Liaison Service or Bone Health Clinic is recommended for osteoporosis evaluation and secondary fracture prevention 4

Delaying surgery beyond 48 hours dramatically increases complications and mortality 2
Using internal fixation for displaced fractures in elderly patients provides inferior outcomes compared to arthroplasty 1
Using uncemented stems significantly increases periprosthetic fracture risk in osteoporotic bone 1, 2
Choosing THA in demented patients with multiple comorbidities is not recommended due to high complication rates 2