Femoral Neck Fracture

Background
The number of individuals participating in athletic activities is continually increasing,
whether these individuals are highly competitive athletes or weekend sports enthusiasts. [1, 2]
Stress fractures of the femoral neck are uncommon injuries (see image depicted below). In
general, these injuries occur in 2 distinct populations, (1) young, active individuals with
unaccustomed strenuous activity or changes in activity, such as runners or endurance athletes,
and (2) elderly individuals with osteoporosis. [3] Elderly individuals may also sustain femoral
neck stress fractures; however, hip fractures are much more common and are often
devastating injuries.

Classification of femoral neck

stress fractures.

View Media Gallery

Femoral neck fractures in young patients are usually caused by high-energy trauma.
These fractures are often associated with multiple injuries and high rates of avascular
necrosis and nonunion. Results of this injury depend on (1) the extent of injury (ie, amount of
displacement, amount of comminution, whether circulation has been disturbed), (2) the
adequacy of the reduction, and (3) the adequacy of fixation. Recognition of the disabling
complications of femoral neck fractures requires meticulous attention to detail in their
management.

For excellent patient education resources, see eMedicineHealth's patient education article
Total Hip Replacement.

Epidemiology
Frequency
United States
Stress fractures of the femoral neck are uncommon, but they may have serious consequences.
Markey reported that femoral neck fractures comprise 5-10% of all stress fractures. Certain
groups of athletes, including long-distance runners who suddenly change or add activities,
appear to have a higher prevalence of femoral neck stress fractures compared with the general
population.

Plancher and Donshik reported a prevalence rate of at least 10% for ipsilateral femoral shaft
fractures, of which 30% are missed on the initial presentation. [4] Brukner reported that women
have a higher rate of stress fractures than men, with relative risks ranging from 1.2 to 10 for
similar training volumes. [5] Training errors are the most common risk factors, including a
sudden increase in the quantity or intensity of training and the introduction of a new activity.

A number of factors predispose the elderly population to fractures, including osteoporosis,

malnutrition, decreased physical activity, impaired vision, neurologic disease, poor balance,
and muscle atrophy. Hip fractures are common and are often devastating in the geriatric
population. [6] More than 250,000 hip fractures occur in the United States each year; however,
as reported by Koval and Zuckerman, with an aging population, the annual number of hip
fractures is expected to double by the year 2050. [7]

Prevention of osteoporosis is key to reducing these numbers, as osteoporosis remains the

single most important contributing factor to hip fractures. The prevalence of hip fractures,
regardless of location, is highest among white women, followed by white men, black women,
and black men.

Koval and Zuckerman noted the age-adjusted incidence of femoral neck fractures in the
United States is 63.3 cases per 100,000 person-years for women and 27.7 cases per 100,000
person-years for men. [7] Femoral neck fractures in elderly patients occur most commonly
after minor falls or twisting injuries, and they are more common in women. In addition, Joshi
et al noted stress fractures of the ipsilateral femoral neck as a rare consequence of total knee
arthroplasty. [8] Influencing factors are correction of a significant knee deformity and inactivity
before the total knee arthroplasty.

International

The exact incidence of femoral neck stress fractures is not known. Volpin et al reported a rate
of 4.7% in 194 Israeli military recruits. [9] Zahger et al reported a higher rate of femoral neck
stress fractures in Israeli female military recruits. [10] Insufficiency fractures are more common
in females secondary to osteoporosis.

Functional Anatomy
The femoral aspect of the hip is made up of the femoral head with its articular cartilage and
the femoral neck, which connects the head to the shaft in the region of the lesser and greater
trochanters. The synovial membrane incorporates the entire femoral head and the anterior
neck, but only the proximal half of the posterior neck. The shape and size of the femoral neck
vary widely.

Crock standardized the nomenclature of the vessels around the base of the femoral neck. The
blood supply to the proximal end of the femur is divided into 3 major groups. The first is the
extracapsular arterial ring located at the base of the femoral neck. The second is the
ascending cervical branches of the arterial ring on the surface of the femoral neck. The third
is the arteries of the ligamentum teres.

A large branch of the medial femoral circumflex artery forms the extracapsular arterial ring
posteriorly and anteriorly by a branch from the lateral femoral circumflex artery (see images
shown below). The ascending cervical branches ascend on the surface on the femoral neck
anteriorly along the intertrochanteric line. Posteriorly, the cervical branches run under the
synovial reflection toward the rim of the articular cartilage, which demarcates the femoral
neck from its head. The lateral vessels are the most vulnerable to injury in femoral neck
fractures.

Posterior view of the

extraosseous blood supply to the femoral head.

View Media Gallery

 Anterior view of the
extraosseous blood supply to the femoral head.

View Media Gallery

A second ring of vessels is formed as the ascending cervical vessels approach the articular
margin of the femoral head. From this second ring of vessels, the epiphyseal arteries are
formed. The lateral epiphyseal arterial group supplies the lateral weight-bearing portion of the
femoral head. The epiphyseal vessels are joined by the inferior metaphyseal vessels and
vessels from the ligamentum teres.

Femoral neck fractures frequently disrupt the blood supply to the femoral head (see images
below). The superior retinacular and lateral epiphyseal vessels are the most important
sources of this blood supply. Widely displaced intracapsular hip fractures tear the synovium
and the surrounding vessels. The progressive disruption of the blood supply can lead to
serious clinical conditions and complications, including osteonecrosis and nonunion.
 Posterior view of the
extraosseous blood supply to the femoral head.

View Media Gallery

Anterior view of the

extraosseous blood supply to the femoral head.

View Media Gallery

In 1961, Garden described the classification of femoral neck fractures. In this classification,
femoral neck fractures are divided into the following 4 grades based on the degree of
displacement of the fracture fragment:

Grade I is an incomplete or valgus impacted fracture.

Grade II is a complete fracture without bone displacement.

Grade III is a complete fracture with partial displacement of the fracture

fragments.

Grade IV is a complete fracture with total displacement of the fracture

fragments.

Frandersen et al concluded that clinically differentiating the 4 grades of fractures is difficult.

Multiple observers were able to completely agree on the Garden classification in only 22% of
the cases. Hence, classifying femoral neck fractures as nondisplaced (Garden grades I or II)
or displaced (Garden grades III or IV) is more accurate. See the illustration depicted below.

Garden fracture classification.

View Media Gallery

Femoral neck fractures are usually intracapsular. The femoral neck has essentially no
periosteal layer; hence, all healing is endosteal in origin. The synovial fluid bathing the
fracture may interfere with the healing process. Angiogenic-inhibiting factors in synovial
fluid can inhibit fracture repair. These factors, along with the precarious blood supply to the
femoral head, make healing unpredictable and nonunions fairly frequent.
Bone physiology
Bone is a dynamic tissue, which continually reacts to stressful events. According to data from
Maitra and Johnson, stress fractures result from an imbalance between bone resorption and
bone deposition during the host bone response to repeated stressful events. [11] Most cortical
stress involves tension or torsion; however, bone is weaker in tension and tends to fail by
fracturing along a cement line.

Maitra and Johnson went on to report that tension forces promote osteoclastic resorption,
whereas compressive forces promote an osteoblastic response. [11] With repeated stress, new
bone formation cannot keep pace with bone resorption. This inability to keep up results in
thinning and weakening of cortical bone, with propagation of cracks through cement lines,
and, eventually, the development of microfractures. Without proper rest to correct this
imbalance, these microfractures can progress to clinical fractures, the sine qua non of
overuse.

A stress fracture is the result of a dynamic process over time, unlike an acute fracture, which
is usually the result of a single supraphysiologic event. Markey reported that stress fractures
can be described as a normal host response to abnormal stress, and this is different from
insufficiency fractures, which are an abnormal host response to normal stresses. [12]

Devas, in 1965, classified stress fractures into 2 types that differ radiologically and have
different clinical outcomes. [13] The first is the tension stress fracture, which results in a
transverse fracture directed perpendicular to the line of force transmitted in the femoral neck
and originates at the superior surface of the femoral neck. This fracture pattern is at increased
risk for displacement. These fractures carry a risk for further advancement of the fracture line
superiorly and eventual displacement, leading to nonunion and avascular necrosis. Hence,
early diagnosis and treatment are essential.

The second type is a compression type of femoral neck stress fracture, which has evidence of
internal callus formation on radiographic images. The fracture is usually located at the
inferior margin of the femoral neck without cortical discontinuity. This fracture pattern is
thought to be mechanically stable. The compression fracture occurs mostly in younger
patients, and continued stress does not usually cause displacement. The earliest radiographic
evidence of a compression stress fracture is usually a haze of internal callus in the inferior
cortex of the femoral neck. Eventually, a small fracture line appears in this area, and it
gradually scleroses.

Fullerton and Snowdy described a femoral neck stress fracture classification with the
following 3 categories [14] : (1) tension, (2) compression, and (3) displaced, as depicted below.
Tension fractures occur on the superolateral aspect of femoral neck and are at high risk for
displacement. Compression fractures are similar to those described by Devas, which occur on
the inferomedial aspect of the femoral neck and have a low risk for displacement.
 Classification of femoral neck
stress fractures.

View Media Gallery

Sport-Specific Biomechanics
Several theories have been developed to explain the mechanisms of femoral neck stress
fractures and the biomechanics of the hip. Nordin and Frankel described the biomechanics of
the hip. The load on the femoral neck can exceed 3-5 times the body weight when an
individual is walking or running. Gravity acts on the center of the body mass, which results in
torque on the medial aspect of the hip joint. This torque is counterbalanced by the contraction
of the gluteus medius and minor. The total load on the femoral head is the sum of the forces
producing these 2 torque forces. Then, these forces on the femoral head are transmitted
through the femoral neck to the shaft, which create a significant amount of stress on the
femoral neck as a result of compression and bending.

Minimal tension or compressive strains have been confirmed to occur in the superior aspect
of the femoral neck during a normal single-leg stance. When tension increases, the inferior
aspect of the femoral neck takes over the burden of damping the forces of compression.
When a patient bends forward, stress is induced on the superior aspect of the femoral head;
however, counter traction of the abductor muscles also occurs. Hence, if the gluteus medius
muscle is fatigued, the strain is placed entirely on the superior aspect of the femoral neck.
This strain can predispose patients to femoral neck stress fractures. If the abductor muscles
fatigue and are unable to provide normal tension, the tensile stress in the femoral neck
increases.

Muscle fatigue has been implicated as a contributing factor in the development of stress
fractures. Muscle imbalance leads to changes in the application of stress across the femoral
neck that may exceed the bone's capability to respond appropriately to stress. Muscle fatigue
secondary to repetitive activity can decrease its shock-absorbing capacity so that higher peak
stresses occur in the femoral neck. This can lead to gait abnormalities, which, in turn, can
alter the body's center of gravity and change the patterns of stress placed on the femoral neck.

In the 1960s, Frankel proposed that femoral neck fractures occur in the presence of a high
ratio of axial load to bending load. Altered muscle balance may also increase the risk of a hip
fracture. Another theory is that a fall onto the hip with a direct blow to the greater trochanter
may generate an axial force along the neck, creating an impaction fracture. The combination
of axial and rotational forces has also been proposed as a mechanism.

The miserable malalignment syndrome combines femoral neck anteversion, genu valgum,
increased Q-angle, tibia vera, and compensatory foot pronation that may not allow
individuals to compensate for overuse. Leg-length discrepancy may also predispose
individuals to injuries by creating an unequal distribution of stress and tension across the hip
joint.

History
Establishing a diagnosis in an athlete experiencing groin or hip pain with ambulation begins
with a detailed history and physical examination. The basic history should include a temporal
account of the patient's symptoms and a complete description of complaints. The clinician
should ask the patient whether the symptoms are associated with participation in a specific
sport or activity. A comprehensive training history should be obtained, and recent changes in
activity level, equipment, intensity levels, and technique should be noted.

A careful menstrual history should be obtained from all female patients.

Amenorrhea is often associated with decreased serum estrogen levels.
Lack of protective estrogen leads to decreases in bone mass. The female
athlete triad of amenorrhea, osteoporosis, and disordered eating affects
many active women. Signs and symptoms of the female triad include the
following:

o Fatigue

o Anemia

o Depression

o Cold intolerance

o Lanugo

o Eroded tooth enamel

o Use of laxatives

Poor eating habits can lead to disturbances of the endocrine,

cardiovascular, and gastrointestinal systems and to irreversible bone loss.
The clinician should be alert to stress fractures and understand the
possible signs of the female athlete triad, particularly noting unusual
fractures that occur from minimal trauma.

Most athletes describe an insidious onset of pain over 2-3 weeks, which
corresponds with a recent change in training or equipment. Typically,
runners have recently increased their mileage or intensity, changed their
 terrain, or switched running shoes. The physician should inquire about the
individual's training log and mileage.

Features common to all stress fractures include the following:

o Participation in repetitive cyclic activity

o Insidious onset of pain

o Recent change in activity or equipment

o Atraumatic history

o Pain with weight bearing

o Relief of pain with rest

o Menstrual irregularities

o Predisposing osteopenia

Patients usually report a history of gradual- or acute-onset anterior hip,

groin, or knee pain that worsens with exercise. A typical feature of a stress
fracture is a history of exercise-related localized pain that increases with
activity and either abates with rest or persists with less forceful activity.
Pain progressively worsens with continued training. The pain is
reproducible with repeated activity, and it is relieved with rest.

The examiner should inquire whether these symptoms have occurred in

the past, and, if so, whether the patient tried using ice or heat or any
medications (eg, acetaminophen, aspirin, nonsteroidal anti-inflammatory
drugs [NSAIDs]). Questions should be asked about previous participation in
a physical therapy program, and the physician should attempt to
understand the treatment plan used.

Physical
A comprehensive physical examination of the athlete with groin or hip pain should include an
in-depth evaluation of the neurologic and musculoskeletal systems. Combining the findings
from the history and physical examination should increase the overall predictive value of the
evaluation process. The degree and type of fracture usually dictate the severity of clinical
deformity.

Inspection: The examination begins with observation of the patient during

the history portion of the evaluation. Note any grimacing or abnormal gait
patterns. Patients with displaced femoral neck fractures are usually unable
to stand or ambulate. Observe the iliac crest for any difference in height,
which may indicate a functional leg-length discrepancy. Alignment and
length of the extremity is usually normal; however, the classic
presentation of patients with displaced fractures is a shortened and
externally rotated extremity. Assessing for any muscle atrophy or
asymmetry is also important.
 Palpation: Determine any tender points in the anterior groin and hip
regions. The most common physical feature of stress fractures in general
is local bony tenderness; however, the neck of the femur is relatively deep
and bony pain or tenderness may be absent. Palpate the trochanter for
any tenderness that might indicate trochanteric bursitis.

Range of motion: Determine the range of motion for hip flexion, extension,
abduction, adduction, and internal and external rotation and for knee
flexion and extension. Findings include pain and restriction at the end of
passive range of motion at the hip. Perform a passive straight-leg raise,
Thomas, and rectus femoris stretch test. Examine the iliotibial band by
performing the Ober test.

In addition to range of motion of the hip, assess the spine and other lower
extremity joints, because pain referral patterns may be confusing.
Examine the low back both actively and passively, looking at forward
flexion, side bending, and extension. Perform a straight-leg raise test and
tests for the Lasegue and Bragard signs. A patient with anterior thigh and
knee pain may actually have pathology at the hip joint. Reproduction of
the patient's pain with hip internal rotation, external rotation, or other
provocative maneuvers may further distinguish hip pathology from spine
involvement.

Muscle strength: Manual muscle testing is important to determine whether

weakness is present and whether the distribution of weakness corresponds
to any nerve injuries. Additionally, evaluate the dynamic stabilizers of the
pelvis, including hip flexors, extensors, and abductors. A Trendelenburg
gait pattern is indicative of hip abduction weakness. Test hip flexion (L2,
L3), extension (L5, S1, S2), abduction (L4, L5, S1), and adduction (L3, L4).

Sensory examination: Upon sensory examination, a dermatomal decrease

or loss of sensation can indicate or exclude any specific nerve damage.
Muscle stretch reflexes are helpful in the evaluation of patients presenting
with hip pain. Abnormal reflexes can indicate nerve root abnormality. The
asymmetry of reflexes is most significant; therefore, a patient's reflexes
must be compared with the contralateral side.

Hop test: Approximately 70% of patients with stress fractures of the femur
demonstrate a positive hop test result. The hop test involves the patient
hopping on the affected leg to reproduce symptoms. Other maneuvers
that can place a stress on the femur also may reproduce pain.

Causes
Training errors are the most common risk factors for femoral neck fractures, including a
sudden increase in the quantity or intensity of training and the introduction of a new activity.
Other factors include low bone density, abnormal body composition, dietary deficiencies,
biomechanical abnormalities, and menstrual irregularities.

Predisposing factors, such as anatomic variations, relative osteopenia,

poor physical conditioning, systemic medical conditions that demineralize
bone, or temporary inactivity, can make bone more susceptible to stress
fractures. As reported by Monteleone, studies have indicated that women
 have an increased incidence of stress fractures, which may be the result of
anatomic variations. [15] Women tend to direct axial force during weight
bearing along different axes of long bones compared with men. Women
also have 25% less muscle mass per body weight than men. This may
concentrate, rather than dissipate, the stabilizing forces through the bony
anatomy.

Markey reported that Hersman et al documented women have a higher

incidence of stress fractures. [12] This higher incidence is partly a result of
mechanical differences and anatomic variations between men and women.
Differences in women include various stride lengths, number of strides per
distance, a wider pelvis, coxa vara, and genu valgum.

Exercise-induced endocrine abnormalities are well known to result in

amenorrhea or nutritional deficiencies, which can lead to bone
demineralization and can place these patients at risk for various overuse
injuries. Stress fractures, especially in trabecular bone, have shown a
decrease in bone mineral content. This decrease can be reproduced by a
decrease in circulating estrogen, which is observed in amenorrheic female
athletes. Lack of protective estrogen leads to a decrease in bone mass.
The female athlete triad of amenorrhea, osteoporosis, and disordered
eating affects many active women. Irreversible bone loss places the
patient at a higher risk for fractures.

Most people are not competitive athletes and may not be at a level of
optimum fitness. Individuals often force themselves to participate at a
level for which they are not physically fit. Flexibility, muscle strength, and
neuromuscular coordination contribute to injuries when individuals are not
properly trained.

Differential Diagnoses
Osteitis Pubis

Slipped Capital Femoral Epiphysis

Snapping Hip Syndrome

Laboratory Studies
See the list below:

Laboratory studies generally are not necessary for the diagnosis of

femoral neck fractures.

Imaging Studies
See the list below:

Plain radiographs

o Plain radiographs have traditionally been ordered as the initial step

in the workup of hip fractures. The main purpose of x-ray films is to
 rule out any obvious fractures and to determine the site and extent
of the fracture. Plain radiographs have poor sensitivity. The
presence of periosteal bone formation, sclerosis, callus, or a fracture
line may indicate a stress fracture; however, a plain radiograph may
appear normal in a patient with a femoral neck stress fracture, and
radiographic changes may never appear.

o Radiographs may show a fracture line on the superior aspect of the

femoral neck, which is the location for tension fractures. Tension
fractures must be distinguished from compression fractures, which,
according to Devas [13] and Fullerton and Snowdy, [14] are usually
located on the inferior aspect of the femoral neck.

o The standard radiographic examination of the hip includes an

anteroposterior view of the hip and pelvis and a cross-table lateral
view. The frog-leg lateral view is poorly tolerated and may result in
fracture displacement. If a femoral neck fracture is suggested, an
internal rotation view of the hip may be helpful to identify
nondisplaced or impacted fractures. If a hip fracture is suggested
but not seen on standard x-ray films, a bone scan or magnetic
resonance imaging (MRI) study should be performed.

Bone scanning

o Bone scans can be helpful when a stress fracture, tumor, or

infection is suggested. Bone scans are the most sensitive indicator
of bone stress, but they have poor specificity. Shin et al reported
that bone scans have a 68% positive predictive value. [16] Bone scans
are limited by relatively poor spatial resolution of the pertinent
anatomy of the hip.

o In the past, a bone scan was thought to be unreliable before 48-72

hours after a fracture; however, a study by Holder et al found a
sensitivity of 93%, regardless of the time from injury. [17]

MRI

o MRI has been shown to be accurate in the assessment of occult

fractures and can be reliably performed within 24 hours of the
injury; however, these studies are expensive.

o With MRI, a stress fracture typically appears as a fracture line at the

cortex surrounded by an intense zone of edema in the medullary
cavity.

o In a study by Quinn and McCarthy, T1-weighted MRI findings were

found to be 100% sensitive in patients with equivocal radiographic
findings. [18] Shin et al showed that MRI findings are 100% sensitive,
specific, and accurate in identifying a femoral neck fracture. [16]
Acute Phase
Rehabilitation Program
Physical Therapy

The goals of treatment in patients with femoral neck fractures are to promote healing, to
prevent complications, and to return function. The primary goal of fracture management is to
return the patient to his or her premorbid level of function. This is completed with either
surgical or nonsurgical management. Several factors must be considered before a treatment
plan is recommended.

With uncomplicated fractures of the femoral neck, treatment for the athlete should focus on
rest and reversing any training errors. Modifying one's risk factors is also important at this
point to prevent progression of the fracture.

A physical therapist may be useful for reinforcing the physician's instructions for rest and
helping the patient modify his or her training program to allow healing. The athlete can
maintain physical fitness and mobility by exercising the remaining extremities and
performing nonweight-bearing strengthening activities that do not cause strain on the
affected hip joint. The physical therapist can evaluate the patient for any gait or anatomic
abnormalities that may have predisposed the patient to development of the fracture. Some
patients may need orthotics to prevent excessive pronation, which causes increased stress on
the femoral neck. The physical therapist completes patient education throughout the
rehabilitation process, whether surgical or nonsurgical treatment is rendered.

Medical Issues/Complications
A patient's medical condition must be considered when considering surgical repairs of
femoral neck fractures. If the nonoperative approach is taken, the patient should be mobilized
as soon as possible to avoid the complications of prolonged immobilization.

Most complications are associated with fracture displacement or a delay in diagnosis.

Complications include delayed union, nonunion, refracture, osteonecrosis, and avascular
necrosis. Early fixation failure (within 3 mo of surgery) occurs in 12-24% of displaced
femoral neck fractures treated by internal fixation.

In a long-term study that followed elderly patients treated with internal fixation, Blomfeldt et
al reported a hip complication rate of 42% and a reoperation rate of 47% at 48 months. [19]
Stappaerts found that the most important factors associated with loss of fixation were
advanced age and inaccurate reduction. [20]

Scheck emphasized the importance of posterior comminution of the femoral neck as a cause
of fixation failure and nonunion. [21] Additionally, Heetveld et al reported that no difference
was noted between osteopenic and osteoporotic patients treated with internal fixation when
considering revision to arthroplasty. [22]
Surgical Intervention
The decision for operative or nonoperative treatment of femoral neck fractures and the
decision regarding the type of surgical intervention are based on many factors. [23] This article
does not address all these issues. Consultation with an orthopedist is necessary. Tension
fractures are potentially unstable and may require operative stabilization. Nondisplaced
femoral neck fractures may need to be stabilized with multiple parallel lag screws or pins.

The treatment of a displaced fracture is based on the person's age and activity level. In the
elderly population, premorbid cognitive function, walking ability, and independence in
activities of daily living should be considered when determining the optimal method of
surgical repair.

Compression fractures are more stable than tension-type fractures, and they can be treated
nonoperatively. Treatment for nondisplaced fractures is bed rest and/or the use of crutches
until passive hip movement is pain free and x-ray films show evidence of callus formation.
Patients should be monitored closely with serial x-ray films, because the risk of displacement
of the fracture is high. Immediate open reduction and internal fixation is indicated if the
fracture widens.

A displaced fracture in a young patient is an orthopedic emergency, and early open reduction
and internal fixation is necessary. The prognosis for returning to a high level of sport
participation is poor in this situation. In elderly patients, treatment options include open
reduction and internal fixation or prosthetic replacement.

The decision between these options should be made on an individual basis. A series of studies
by Blomfeldt et al demonstrated that total hip replacement in elderly patients with higher
cognitive function and a more independent lifestyle was associated with a significantly lower
complication and reoperation rate. [19] Additionally, health-related quality of life was superior
at 2 years and equal at 4 years when compared with patients treated with internal fixation.
Conversely, neither total hip replacement nor internal fixation was found to be advantageous
in patients with severe cognitive impairment. Both prosthetic replacement and internal
fixation were associated with a high rate of mortality and decreased functioning in activities
of daily living.

In patients with an overt fracture line and no displacement on x-ray films, the initial treatment
is complete nonweight-bearing ambulation with crutches. The clinician should obtain an x-
ray film every 2-3 days the first week to detect any extension or widening of the fracture line.
If pain does not resolve or if evidence of fracture line expansion is noted, internal fixation is
indicated. In patients with a positive bone scan result and no visible fracture line on the x-ray
film, the initial treatment is proportional to the severity of the symptoms. Treatment begins
with nonweight-bearing or partial weight-bearing (based on symptoms) activities with
crutches until symptoms resolve.
Wang et al conducted a meta-analysis of randomized controlled trials comparing the
outcomes of bipolar hemiarthroplasty with total hip arthroplasty for treating femoral neck
fractures in healthy elderly patients. The study concluded that for healthy elderly patients
with displaced femoral neck fractures, treatment with bipolar hemiarthroplasty led to better
outcomes regarding dislocation rate, while total hip arthroplasty was better regarding
acetabular erosion rate and reoperation rate. [24]

Consultations
For high-risk fractures that require surgical intervention, consultation with an orthopedic
surgeon is necessary.

Recovery Phase
Rehabilitation Program
Physical Therapy

Once the painful symptoms of a stable femoral neck fracture are controlled during the acute
phase of treatment, strengthening exercises for the hip stabilizers and associated muscles can
be initiated. The main objectives are to improve and restore range of motion of the hip.

Once the patient is pain free, weight bearing can be progressed. When patients are able to
tolerate partial weight-bearing ambulation, general conditioning workouts, including
swimming and cycling, are permitted. Serial x-ray films are obtained at weekly intervals until
the patient can ambulate with full weight bearing and no pain.

Running is gradually reintroduced, and progression of distance is slow. If pain occurs, a

couple of days of rest are recommended, mileage is reduced, and then mileage is progressed
again depending on the individual's symptoms.

Surgery is indicated for patients with overt fractures or displacement on the tension side.
Usually, fixation with a plate and screws is used. Postoperatively, the patient rests until pain
resolves and then progresses to full activity as healing occurs. Once the plate is removed,
further rehabilitation is needed. Removal of the plate depends on the age and activity level of
the patient. Some patients prefer weight bearing with crutches. Patients are usually allowed to
return to running; however, contact sports are limited.

Strengthening of the gluteus medius, a hip abductor, is important for postoperative stability.
Other important muscles include the iliopsoas; gluteus maximus; adductor magnus, longus,
and brevis; quadriceps; and hamstrings. Functional goals include normalizing the patient's
gait pattern. Activities are then progressed to sport-specific training and strengthening.

Maintaining aerobic conditioning throughout the rehabilitation process is important. If

protected or nonweight-bearing ambulation is necessary, then upper body exercise, such as
an upper body ergometer, can be used. Once partial weight-bearing ambulation is allowed,
aquatic training may be used, such as swimming or deep-water running.
Surgical Intervention
Patients with overt fractures or displacement on the tension side require surgical intervention
for proper healing. Generally, internal fixation is required with the use of a plate and screws.

Maintenance Phase
Rehabilitation Program
Physical Therapy

The maintenance phase represents the final phase of the rehabilitation process in patients with
femoral neck fractures. Eccentric muscle-strengthening exercises, including more dynamic
conditioning exercises (eg, with a large gym ball), are added to the patient's program. In
addition, sport-specific training should be incorporated so that the athlete can maintain
muscle balance.

Medication Summary
As with all fractures, pain management should be a primary concern. Often, acetaminophen
or an NSAID is prescribed for the acute pain of a fracture. However, additional pain relief
may be necessary if the patient does not have relief with acetaminophen or NSAIDs alone. In
this case, an opiate may be required, particularly for breakthrough pain. Adjustment of pain
medications may be necessary, especially in the acute phase.

Analgesics
Class Summary
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote
pulmonary toilet, and have sedating properties, which are beneficial for patients who have
sustained injuries.

Acetaminophen (Tylenol, Feverall, Tempera, Aspirin-Free Anacin,

Tylenol-3)

View full drug information

Indicated for mild to moderate pain. DOC for pain in patients with documented
hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral
anticoagulants.

Ibuprofen (Motrin, Ibuprin)

View full drug information

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by
decreasing prostaglandin synthesis.
Oxycodone (OxyContin, Percocet, Roxicet, Roxilox, OxyIR, Tylox,
Roxiprin)

View full drug information

Analgesic with multiple actions similar to those of morphine; may produce less constipation,
smooth muscle spasm, and depression of cough reflex than similar analgesic doses of
morphine.

Return to Play
Return-to-play criteria in patients following femoral neck fractures require the athlete to have
an absence of signs or symptoms of the original injury, full range of motion, normal strength
and flexibility, and normal sport-specific mechanics. Athletes must be aware of their own
limitations, which is particularly important for the individual gradually returning to a
competitive level of activity after injury. [25]

Complications
Complications include recurrent stress fractures.

Prevention
Patient education is an important factor in the prevention of stress fractures. Female athletes
should decrease their risk of recurrent fractures by maintaining adequate muscle mass and
bone density.

Maintaining proper flexibility is also thought to play a significant role in the prevention of
sports-related injuries. Additionally, improvement in aerobic fitness can increase blood flow
and oxygenation to all tissues, including the muscles and bones, and it would be a reasonable
addition to any rehabilitation and prevention program. Seasonal athletes should be
encouraged to cross-train all year or at least undergo preconditioning before participating in
their particular sport.

Prognosis
Depending on the nature of the fracture, the athlete may or may not return to premorbid
functioning. A displaced stress fracture of the femoral neck may end the career of an elite
athlete even if correctly treated. Early diagnosis and treatment may prevent displacement of
the fracture and thus improve the prognosis.

Education
The patient with a femoral neck fracture should have a good understanding of his or her
diagnosis and the benefits and risks of treatment. Completing education throughout the
rehabilitation process is very important for patients to obtain the most optimal results and to
possibly to return to their previous level of activity or specific sport.

Patients should take an active role in their care and understand what is necessary for proper
healing, in addition to being instructed in a home exercise program for regaining their
strength and range of motion of the affected lower extremity. Patient education is crucial to
the prevention of recurrent neck stress fractures.

http://emedicine.medscape.com/article/86659-followup#showall