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Femoral shaft fractures can occur from a fall from standing in patients with a history of osteoporosis; however, most femoral shaft fractures occur in road traffic accidents. Other causes include a fall from height and gunshot wounds. Patients can present similarly, with a shortened externally rotated leg. However, in an elderly patient presenting with a fall, a neck of femur fracture is the more common aetiology
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Femoral shaft fracture
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Osteoarthritis is a degenerative arthritis that comes on over years and is worsened by movement. The rapid onset of pain and examination findings, in this case, make a diagnosis of neck of femur fracture more likely
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Osteoarthritis
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Neck of femur fractures are a relatively common fracture, typically occurring in elderly patients. Neck of femur fractures typically occur after a minor fall and present with sudden onset pain, with a shortened and externally rotated leg on examination. This position is formed by several muscles (including iliopsoas and hip abductors) creating force, pulling up and externally rotating the leg. Smoking and low BMI are risk factors for osteoporosis. The diagnosis is confirmed by hip x-ray (AP and lateral view), and management varies on fracture classification, e.g. intracapsular/extracapsular, non-displaced/displaced
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Left neck of femur fracture
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Hip dislocation typically occurs after a road traffic accident. It usually presents with shortening of the leg, as in this case. However, the leg is internally rotated, not externally rotated. This is because most hip dislocations are posterior, meaning the femoral head travels posteriorly to the acetabulum
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Hip dislocation
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Septic arthritis is a life-threatening condition associated with infection in the joint. It presents with a history of red, hot, swollen joint that comes on over hours-days, which may be accompanied by fever and sepsis. The history of onset of pain after a fall and the examination findings make a diagnosis of neck of femur fracture more likely
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Septic arthritis
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"Out For Intense Disco" - Outward = Fracture and Internal = Dislocation
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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 78-year-old female presents to the emergency department with left hip pain that came on immediately following a fall. She is a current smoker and has a body mass index of 18.8. On examination, the left leg is shortened and externally rotated.

What is the most likely diagnosis?
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