Updated: 5/29/2019

Femoral Neck Fracture

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  • 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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Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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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? Review Topic | 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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