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QuestionChoice
According to the radiographic findings, which show a **Garden stage III hip fracture**, this patient requires immediate surgical intervention to repair the fracture and stabilise the joint. A hemiarthroplasty would be the safest choice due to her age and comorbidities, as it carries a relatively lower risk compared to a total hip replacement.
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a
Hemiarthroplasty
QuestionChoice
Intramedullary nailing is the "gold standard" treatment for managing femoral shaft fractures.
62071
d
Intramedullary nail
QuestionChoice
Due to her current medical conditions, which are currently impairing her mobility, it would not be advisable for her to undergo a total hip replacement at this age.
62069
b
Total hip replacement
QuestionChoice
A Dynamic hip screw is regarded as the 'gold standard' implant for application in all extracapsular fractures. This is an intra-capsular fracture.
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c
Dynamic hip screw
QuestionChoice
The clinical scenario is a surgical emergency that requires prompt intervention to stabilise the fracture and restore function to the hip joint. While physiotherapy may be an important part of the patient's rehabilitation after the surgery, it is not an appropriate treatment for the fracture itself.
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e
Physiotherapy
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# Summary

A fracture of the neck of the femur is a break occurring in the upper part of the femur, just below the ball-and-socket hip joint. This fracture is common among the elderly population, particularly those with osteoporosis. Notable symptoms include severe hip or groin pain, an inability to bear weight on the affected leg, and external rotation and shortening of the affected leg. Diagnosis typically involves X-rays, though CT scans or MRI may be employed for more complex cases. Management is primarily surgical, with options including cannulated screw fixation, dynamic hip screw, hemiarthroplasty, and total hip arthroplasty, chosen based on factors such as the patient's age, health, and the type of fracture. Complications can include non-union, avascular necrosis, deep vein thrombosis, and pulmonary embolism.

# Definition

A fracture of the neck of the femur is a type of hip fracture that specifically involves the upper part of the femur, just below the ball of the hip's ball-and-socket joint.

# Types of Neck of Femur Fracture

Fractures of the neck of the femur are generally classified into two types based on their location in relation to the hip joint capsule:

-   **Intracapsular Fractures**: These fractures occur within the joint capsule. They are further subdivided into displaced and non-displaced fractures. Displaced fractures carry a high risk of avascular necrosis due to possible disruption of the blood supply to the femoral head.
    
-   **Extracapsular Fractures**: These fractures occur outside the joint capsule and include intertrochanteric and subtrochanteric fractures. They have a better prognosis due to a lower risk of avascular necrosis.

# Epidemiology

Fractures of the neck of the femur are a common injury, particularly in older individuals. This is largely attributed to the increased prevalence of osteoporosis in this population, which makes the bones more susceptible to fractures.

# Aetiology

The main cause of a fracture to the neck of the femur is a fall, often in the elderly and those with weakened bones due to osteoporosis. Other potential causes can include high-energy trauma such as car accidents, especially in younger individuals.

# Signs and Symptoms

Patients with a fractured neck of femur commonly present with:

-   Severe pain in the hip or groin
-   Inability to bear weight on the affected leg
-   Shortening and external rotation of the affected leg
-   Swelling or bruising over the hip area

# Differential Diagnosis

The differential diagnosis for a fractured neck of femur should include other injuries that could present with similar symptoms:

-   **Intertrochanteric Fracture**: Another type of hip fracture, characterised by pain in the hip or groin, inability to bear weight, and often shortening and external rotation of the affected leg.
-   **Pelvic Fracture**: Can be caused by falls or high-energy trauma. Symptoms can include severe pain in the hip or groin, inability to bear weight, and possible signs of internal bleeding.
-   **Hip Dislocation**: Usually a result of high-energy trauma, symptoms include severe hip pain, inability to move the leg, and a visibly deformed hip.

# Investigations

The primary investigation for a suspected fractured neck of femur is a hip X-ray, which typically reveals the fracture and its severity. In cases where the fracture is not clear on X-ray, a CT scan or MRI may be necessary.

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# Management

Management of a fractured neck of the femur is primarily surgical. The choice of surgical intervention depends on several factors, including the type of fracture, the patient's age, general health, and mobility prior to the injury.

-   **Cannulated Screw Fixation**: This is often used for non-displaced intracapsular fractures. The procedure involves the insertion of screws across the fracture line to stabilise it.
    
-   **Dynamic Hip Screw (DHS)**: This technique is usually used for stable, extracapsular fractures. It involves the insertion of a single large screw into the femoral head, combined with a side plate fixed to the femoral shaft.
    
-   **Hemiarthroplasty**: This involves replacing the femoral head and neck with a prosthesis. It is typically performed for displaced intracapsular fractures in older patients with lower activity levels, as these fractures have a high risk of non-union and avascular necrosis.
    
-   **Total Hip Arthroplasty (THA)**: This procedure involves the replacement of both the femoral head and the acetabulum with prosthetic components. It is typically used for displaced intracapsular fractures in younger, more active patients or older patients with pre-existing osteoarthritis.
    

# Complications

Potential complications from a fracture of the neck of the femur include:

-   Non-union of the fracture
-   Avascular necrosis due to interruption of blood supply to the femoral head
-   Deep vein thrombosis (DVT)
-   Pulmonary embolism (PE)
-   Infection
-   Dislocation of the hip prosthesis, in cases where arthroplasty has been performed

# References

[Click here to read more about fractures of the neck of femur](https://teachmesurgery.com/orthopaedic/hip/femoral-neck-fractures/)
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An intracapsular fractured neck of femur.
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A 85-year-old woman presents to the emergency department with severe pain in her left hip and difficulty walking and bearing weight on the left leg. She reports falling on her left side while getting out of bed this morning. She recently had a stroke a few months ago that left her with paralysis on the left side, and she is using a frame while walking. Past medical history includes hypothyroidism, osteoporosis, hypercholesterolaemia and heart failure.

Examination reveals a shortened and externally rotated left lower limb. X-ray shows a complete and partially displaced subcapital fracture of the neck of the femur.

Which of the following management option is the most appropriate choice?
a