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 Associated conditions osteoporosis 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 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 Prognosis Immediate surgical repair is associated with better outcomes