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

Authors' Preferred Treatment

At our institution, the workup for an elderly patient presenting with hip pain after a fall starts with plain radiographs including an AP view of the pelvis and a shoot-through lateral view of the affected hip (Figure 8). When a nondisplaced FN fracture is visible on the AP radiograph, the lateral view is carefully scrutinized for posterior angulation using the methods described by Palm et al.[6] CT is not routinely performed for fractures visible on plain radiographs. On rare occasions, a noncontrast CT may be obtained if radiographs are of poor quality or fracture displacement is questionable. CT may also be warranted if there is concern for a pathologic process or fracture extension into the intertrochanteric/subtrochanteric region. In the setting of a presumed occult hip fracture, a noncontrast MRI is obtained.

Figure 8.

Flowchart showing the author's preferred treatment. *According to surgeon preference. †Based on patient function, cognition and comorbidities. ROM = range of motion, THA = total hip arthroplasty

All nondisplaced FN fractures are treated surgically (aside from the very rare instance in which a patient is deemed medically unable to tolerate the procedure). Patients are evaluated by the internal medicine hospitalist team and optimized for surgery. Our goal is to perform the surgical intervention as soon as medically feasible, ideally within 24 hours.[19]

For patients with favorable fracture characteristics, we perform sliding hip screw fixation with a two-hole side plate and 6.5 mm antirotational screw or percutaneous fixation with three partially threaded 7.3 mm cannulated screws. All fracture fixation is performed in situ because we feel that fractures with displacement substantial enough to necessitate reduction are better treated with arthroplasty.

For patients with fracture characteristics that increase the risk of failure (including posterior tilt ≥20°[6,14,15] or disruption of the medial cortex[33]), we prefer to perform primary arthroplasty, especially in patients who are older than 80 years.[15] Based on the patient's function, cognition, and comorbidities, this could be total hip arthroplasty or hemiarthroplasty, both performed with cemented femoral fixation and an anterior-based approach to minimize the risk of dislocation.