Current Trends in the Evaluation and Management of Nondisplaced Femoral Neck Fractures in the Elderly

Kanu Okike, MD, MPH; Ian G. Hasegawa, MD


J Am Acad Orthop Surg. 2021;29(4):e154-e164. 

In This Article

Abstract and Introduction


Nondisplaced (Garden I and II) femoral neck (FN) fractures are commonly encountered by the practicing orthopaedic surgeon. Although these fractures are primarily classified based on the AP radiograph, the lateral radiograph should be closely scrutinized as well because posterior tilt has emerged as a consistent predictor of fixation failure. Internal fixation has for many years been the standard of care, with both cannulated screws and the sliding hip screw representing acceptable options. However, the outcomes after fixation of Garden I and II FN fractures have not been uniformly positive, with the rates of revision surgery ranging from 8% to 27%. Complications after fixation of nondisplaced FN fractures include nonunion, fixation failure, osteonecrosis, and femoral shortening causing inferior hip function. For these reasons, arthroplasty is increasingly considered a viable option in the treatment of these fractures, especially in the presence of factors that predispose to failure after fixation. Novel devices for FN fixation have recently been developed, although clinical data supporting their use are sparse at the present time.


Nondisplaced femoral neck (FN) fractures in the elderly represent one of the most common injuries encountered by orthopaedic surgeons. The annual incidence of FN fractures in those 65 years and older in the United States has recently been reported to be 146 per 100,000.[1] Although the true incidence of nondisplaced FN fractures is difficult to estimate, hip registry data indicate that nondisplaced fractures may account for 20% to 50% of all FN fractures in those 65 years and older.[2,3]

Although many surgeons might consider the treatment of nondisplaced FN fractures to be routine, the available data suggest otherwise. The FAITH trial documented a revision surgery rate of 16% after fixation of these injuries,[4] and other recent studies have reported revision surgery rates as high as 21%[5] to 27%.[6] This is in addition to the high rates of mortality (18% to 23% at 1 year)[7] which have been documented for hip fractures generally.[8] For patients who avoid these most serious complications, recent studies using more sophisticated clinical outcome measures have also documented notable levels of compromised hip function.[9,10] These mediocre outcomes suggest that there may be opportunities for improvement in the management of nondisplaced FN fractures in the elderly.

The purpose of this review is to discuss the current literature regarding the evaluation and management of nondisplaced FN fractures in the elderly, with the goal of allowing the clinician to improve his or her treatment of these common injuries.