Femoral neck fractures are a common pathology within orthopedic trauma surgery. The surgical management is dictated by fracture location, as well as other factors such as stability. These indications are often a hot topic for pimping questions from attendings and residents. In this post, we’ll discuss the important workup and surgical options for femoral neck fractures and prepare you to answer these questions on your clinical rotations.

There are 5 major locations for femoral neck fractures to occur (this classification is specific for the elderly with low-energy fractures. For high energy fractures in young people, use the Pawells classification).

–subcapital: upper third of the femoral neck below the femoral head

–transcervical: middle of the femoral neck

–basicervical: base of femoral neck, above the greater and lesser trochanter

–intertrochanteric: occurs between the greater and lesser trochanter

–subtrochanteric: below the lesser trochanter, extending 5cm down (below is considered a femoral shaft fracture)

Subcapital, transcervical, and basicervical femoral neck fractures follow the same treatment algorithm. They can further be classified as displaced and nondisplaced. 

 

Displaced femoral neck fractures are treated with hemiarthroplasty (lower demand) or total hip arthroplasty (high activity/ higher demand patients). Nondisplaced fractures are treated with percutaneous pinning.

The management of intertrochanteric fractures takes into account the inherent stability of the fracture. There are 4 factors that dictate stability. If any one factor is met, the intertrochanteric fracture is unstable, and surgical management changes accordingly. 

4 factors that communicate instability of an intertrochanteric femur fracture:

1. reverse obliquity: the fracture line is perpendicular to the line drawn from the greater to the lesser trochanter
2. Lateral cortex involvement
3. Calcar comminution: The calcar is an area of thickened bone that is located deep to the lesser trochanter on the posteromedial aspect of the femoral shaft. This area aids in load distribution and provides mechanical support to the proximal femur.
4. Subtrochanteric extension

Stable intertrochanteric hip fractures are commonly treated with short intramedullary femur nails, and less commonly sliding hip screws.

Unstable intertrochanteric hip fractures are treated with long intramedullary femur nails.