Updated: 5/29/2019

Femoral Neck Fracture

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Snapshot
  • A 40-year-old man presents after a motor vehicle accident. The patient reports significant pain in his right groin. On physical exam, his right hip and groin are tender to palpation and the patient is unable to raise his leg. He has significant pain with passive range of motion. The log roll maneuver is positive. Radiography shows a femoral neck fracture.
Introduction
  • Clinical definition
    • fracture of the femoral neck
  • Epidemiology
    • demographics
      • female > male
      • more common in older patients
      • rare in young patients
    • location
      • femoral neck
      • main blood supply to the femoral head is the medial circumflex femoral artery
    • risk factors
      • older age
      • osteoporosis
      • primary bone disease
  • Etiology
    • acute trauma
      • minor trauma, such as falls, in elderly patients who are prone to osteoporosis
      • high-energy trauma in young patients
    • repetitive stress
  • Associated conditions
    • osteoporosis
  • Prognosis
    • immediate surgical repair is associated with better outcomes
Presentation
  • Symptoms
    • severe hip, groin, or thigh pain
    • often presents with a history of recent trauma or fall
  • Physical exam
    • involved leg is abducted and externally rotated and may appear shortened
    • hip is tender to palpation
    • hip pain is elicited with active and passive range of motion
      • involved hip has a limited range of motion
    • log roll maneuver
      • with the patient supine, the clinician internally and externally rotates the leg
      • elicited hip pain with this maneuver suggests a femoral neck fracture
    • patients may still be able to ambulate
Imaging
  • Radiography
    • indication
      • for all patients
    • recommend views
      • anteroposterior radiograph of pelvis
      • lateral radiograph of hip
      • avoid frog-leg radiograph as positioning may cause severe pain and increased displacement
    • findings
      • fracture of the hip
      • loss of trabecular pattern of the femoral neck
      • abnormal neck-to-shaft angle (normal is 125°)
Studies
  • Making the diagnosis
    • based on clinical presentation and imaging
      • there is a high index of suspicion for a fracture of the femoral neck even with a negative radiograph in an elderly patient with osteoporosis
Differential
  • Osteonecrosis of femoral head
    • distinguishing factors
      • radiography does not reveal a femoral neck fracture
      • physical exam does not elicit hip pain with passive or active motion or with the log roll maneuver
Treatment
  • Management approach
    • approach includes management of pain, immobilization of the leg and hip, and surgical correction
    • currently, there is debate as to whether open reduction with internal fixation or arthroplasty is the best option
  • Conservative
    • immobilization
      • indication
        • for all patients while awaiting surgery
  • Medical
    • intravenous analgesic medication
      • indication
        • for pain management
      • modalities
        • opioids, as pain from a femoral fracture is very severe
  • Operative
    • open reduction and internal fixation (ORIF)
      • indications
        • in younger patients
        • all displaced fractures
    • hip arthroplasty
      • indications
        • in older patients
        • when surgery is contraindicated
    • pain management 
      • for very ill patients who can not handle surgery
      • when surgery does not align with patient goals of care
Complications
  • Increased mortality
  • Avascular necrosis of femoral head
  • Osteoarthritis
 

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(M2.OR.12.3) A 95-year-old woman presents to the emergency room with pain in her left hip 12 hours after a fall out of her wheelchair at her assisted care facility. The patient was unattended for several hours following her fall. The patient has severe dementia and needs assistance with all daily activities. She is unable to move her right leg following a left hemispheric stroke 3 months prior to presentation. She has a history of coronary artery disease and diabetes mellitus type II which is poorly controlled. On physical examination, the left thigh is ecchymotic and the left leg is rotated outwards and shortened. A radiograph is obtained as seen in Figure A. Which of the following is the best treatment for this patient? Tested Concept

QID: 103026
FIGURES:
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Casting

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Hip prosthesis

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Pinning

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Reduction

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Rehabilitation and pain management

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M 7 E

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