SUMMARY
Femoral neck fractures are intracapsular injuries that disrupt femoral head blood supply, resulting in high rates of AVN and nonunion. Treatment is guided by patient age, fracture displacement, and functional demand.
EPIDEMIOLOGY
Most common intracapsular hip fracture
Elderly → low-energy falls
Young → high-energy trauma
High mortality:
~20–30% at 1 year
ETIOLOGY & MECHANISM
Elderly:
Osteoporosis + fall
Young:
High-energy trauma
PATHOANATOMY
Intracapsular location → hematoma + tamponade
Retinacular vessel disruption
Limited healing potential (no periosteum, synovial environment)
ANATOMY
MFCA → dominant blood supply
Retrograde flow via neck
Displacement → vascular interruption
CLASSIFICATION
Garden
· Type 1: Incomplete, valgus impacted.
· Type 2: Complete but nondisplaced.
· Type 3: Partially displaced with trabecular disturbance.
· Type 4: Fully displaced.
◦ Clinical Note: Simplified Garden systems divide these into undisplaced (I/II) and displaced (III/IV) to guide surgical strategy.
Pauwels
Based on the vertical angle of the fracture line. Type III (>50°) is subject to high shear forces and carries the greatest risk of nonunion and AVN.
Type I (<30°)
Type II (30–50°)
Type III (>50°)
Vertical fracture → shear ↑ → failure ↑
PRESENTATION
Groin pain
Inability to bear weight
Shortened, externally rotated limb
IMAGING
Radiographs:
AP pelvis
Lateral hip
MRI:
Occult fractures
TREATMENT
General Principles
Early surgery (24–48 h)
Goal: mobilization + complication reduction
TREATMENT ALGORITHM
Young patients (<60)
Emergent ORIF
Aim: femoral head preservation
Methods:
Multiple cannulated screws
DHS (vertical fractures)
Elderly patients
Nondisplaced
Internal fixation
Displaced
Arthroplasty
Patient Type | Treatment |
Low demand | Hemiarthroplasty |
Active | Total hip arthroplasty |
SURGICAL PRINCIPLES
Anatomic reduction
Avoid varus
Screw configuration:
Inverted triangle
COMPLICATIONS
AVN (10–45%)
Nonunion (5–30%)
Fixation failure
Reoperation
PROGNOSIS
Worse with:
Displacement
Delay in surgery
Poor reduction