Femoral neck fractures are intracapsular fractures of the proximal femur that carry 1-year mortality rates approaching 30% and require urgent surgical management, typically within 24–48 hours of injury. [1-2] The following is a comprehensive clinical summary organized for emergency medicine and primary care workflows.
1. History
- Mechanism: Low-energy fall from standing height (elderly), high-energy trauma (young patients) [2]
- Pain location: Anterior groin pain is the hallmark; may radiate to the ipsilateral thigh or knee [1][3]
- Weight-bearing: Inability to ambulate or bear weight on the affected limb [1][3]
- Timing: Acute onset with a clear inciting event; in stress/insufficiency fractures, insidious onset with progressive groin/buttock pain worsened by weight-bearing and activity [1]
- Important negatives: Ask about preceding syncope, chest pain, palpitations, or neurologic symptoms to evaluate the cause of the fall; ask about anticoagulant use [4-5]
2. Alarm Features
- Open fracture or neurovascular compromise (absent distal pulses, sensory/motor deficit)
- Hemodynamic instability suggesting occult hemorrhage (especially with concurrent pelvic or bilateral fractures)
- Fall triggered by syncope, stroke, MI, or PE — the fracture may be secondary to a life-threatening event [6]
- Pathologic fracture signs: pain preceding the fall, history of malignancy, weight loss [1]
- Compartment syndrome (rare but possible with high-energy mechanism)
3. Medications
- Fall-risk-increasing drugs (FRIDs): Opioids (OR 1.60), antidepressants/SSRIs (OR 1.48), benzodiazepines (OR 1.84), antipsychotics (OR 2.30), sedative-hypnotics, loop diuretics (OR 1.36) [7-9]
- Bone-density-reducing drugs: Systemic corticosteroids, levothyroxine, proton pump inhibitors, aromatase inhibitors, anticonvulsants [1][10]
- Anticoagulants: Document DOAC/warfarin use — affects surgical timing. Hip fracture surgery can reasonably proceed <36 hours from last DOAC dose (eGFR >60); warfarin reversal protocols reduce surgical delay [4-5]
- Perioperative antibiotics: Cefazolin 1–2 g IV q8h (or vancomycin if cephalosporin allergy) starting 1–2 hours preoperatively and continuing 24 hours postoperatively [1]
- VTE prophylaxis: LMWH, aspirin, fondaparinux, or DOACs for a minimum of 10–14 days (up to 35 days); aspirin is a safe, effective, and inexpensive alternative per the PREVENT CLOT trial [1][11-12]
- Avoid: Benzodiazepines postoperatively (delirium risk); minimize opioids using multimodal analgesia [13]
4. Diet
- Ensure adequate calcium and vitamin D intake — deficiency is a modifiable risk factor for fracture [1]
- Preoperative fasting per institutional NPO guidelines; resume oral intake early postoperatively
- Moderate-to-high alcohol intake (>27 g/day) and high caffeine intake (>3 cups/day) are associated with 1.5–2× increased fracture risk [1]
- Postoperative nutrition optimization reduces complications; protein supplementation may support wound healing and recovery
5. Review of Systems
- Cardiovascular: Syncope, chest pain, palpitations (evaluate fall etiology)
- Neurologic: Weakness, numbness, gait instability, cognitive decline (delirium risk)
- GU: Urinary symptoms (UTI as delirium precipitant)
- Pulmonary: Dyspnea, pleuritic chest pain (PE risk)
- Constitutional: Weight loss, night sweats, bone pain elsewhere (malignancy screen)
- Endocrine: History of thyroid disease, corticosteroid use, menstrual history in younger patients [1]
6. Collateral History and Family History
- Baseline functional status: Ambulatory with/without assistive device, independent vs. dependent ADLs — critical for surgical decision-making and disposition [14]
- Cognitive baseline: Pre-existing dementia increases delirium risk and affects consent [15]
- Parental hip fracture: Independent risk factor incorporated into FRAX scoring [16-17]
- Social context: Living situation, caregiver availability, home safety hazards (throw rugs, stairs) [14]
- Advance directives and goals of care: Essential in frail elderly patients considering nonoperative management [1]
7. Risk Factors
- Nonmodifiable: Advanced age (women >85 have 10× risk vs. women in their 60s), female sex, prior fracture, metabolic bone disease, bony malignancy, lower socioeconomic status [1]
- Modifiable: Osteoporosis (T-score ≤ −2.5), low BMI (<18.5 kg/m²), physical inactivity, falls, smoking, alcohol use, vitamin D deficiency [1][16]
- Medications: See Section 3 above — polypharmacy with ≥3 FRIDs dramatically amplifies risk [18-19]
- Stress fracture-specific: Endurance athletes, military recruits, female athlete triad/RED-S, sudden training increases [1]
8. Differential Diagnosis
- Intertrochanteric fracture: Extracapsular; similar presentation but ecchymosis more common; managed with intramedullary nail or sliding hip screw [20-21]
- Pubic ramus fracture: Groin/anterior pelvic pain; may coexist; visible on AP pelvis [22]
- Acetabular fracture: High-energy mechanism; CT often needed for diagnosis [22]
- Isolated greater trochanter fracture: Lateral hip pain; usually managed conservatively but must exclude occult intertrochanteric extension [22]
- Hip dislocation: Typically high-energy; posterior dislocation presents with flexion, adduction, internal rotation [23]
- Pathologic fracture: Metastatic disease (breast, lung, prostate, renal, thyroid); lytic lesions on imaging [1]
- Avascular necrosis: Insidious groin pain; risk factors include corticosteroids, alcohol, hemoglobinopathies [3]
- Osteoarthritis: Gradual onset, decreased ROM, joint space narrowing on radiographs [3]
- Lumbar radiculopathy: Referred pain to hip/groin; neurologic exam findings help differentiate
9. Past Medical History
- Prior fractures (strongest predictor of future fracture) [16]
- Osteoporosis diagnosis and treatment status
- Chronic kidney disease (affects DOAC dosing, bone metabolism)
- Dementia/cognitive impairment (delirium risk, consent capacity) [15]
- Cardiovascular disease (perioperative risk stratification)
- Malignancy (pathologic fracture consideration)
- Previous hip surgery or arthroplasty (periprosthetic fracture)
- Anticoagulation indication (AF, VTE, mechanical valve) [4]
10. Physical Exam
- Classic presentation (displaced fracture): Shortened, externally rotated, abducted lower extremity [1][3][14]
- Nondisplaced fracture: May have minimal deformity; pain with log roll, axial loading, and the FABER/FADIR maneuver [1]
- Vital signs: Tachycardia and hypotension may indicate hemorrhage or the medical cause of the fall
- Neurovascular exam: Palpate dorsalis pedis and posterior tibial pulses; assess sensation and motor function distally [14]
- Skin: Inspect for open wounds, ecchymosis (more common in extracapsular fractures), skin tenting [2]
- Contralateral hip and pelvis: Examine for concurrent injuries
- Cognitive assessment: Brief screen (CAM or 4AT) for baseline delirium assessment [15]
11. Lab Studies
- CBC: Baseline hemoglobin (transfusion threshold Hgb <8 g/dL in asymptomatic patients postoperatively) [1][14]
- BMP/CMP: Electrolytes, renal function (affects DOAC management, contrast use)
- Coagulation studies: PT/INR (if on warfarin); anti-Xa level if on DOAC and timing uncertain [4]
- Type and screen: In anticipation of surgery
- Urinalysis: Rule out UTI as delirium precipitant
- Vitamin D level and calcium: For osteoporosis workup (can be obtained during admission)
- TSH: If thyroid disease suspected
- Troponin and BNP: If cardiac event suspected as fall etiology
- Albumin/prealbumin: Nutritional status in frail patients
12. Imaging
- First-line: AP pelvis and cross-table lateral hip radiographs — sufficient for most diagnoses. Avoid frog-leg lateral (risk of fracture displacement) [1][23]
- If radiographs negative but clinical suspicion persists:
- CT hip without contrast: Fast, widely available; sensitivity ~79–94% for occult fractures; also aids surgical planning for known fractures [23]
- MRI hip without contrast: Gold standard for occult fractures; 100% sensitivity with abbreviated protocol (coronal T1 + STIR). Obtain if CT is negative and suspicion remains [23]
- Key imaging findings: Fracture line through the femoral neck; assess displacement (Garden classification) and posterior tilt; look for lytic lesions suggesting pathologic fracture
- ~15% of femoral neck fractures are occult on initial radiographs [2]
The following figure illustrates the surgical treatment options based on fracture characteristics:
13. Special Tests
- Garden Classification: Types I–II (nondisplaced) vs. III–IV (displaced) — drives surgical decision-making, though interobserver reliability is poor; the displaced vs. nondisplaced distinction is more clinically useful [20-21][24]
- Posterior tilt assessment: >20° on lateral radiograph predicts fixation failure; may favor arthroplasty [25-26]
- Pauwels Classification: Fracture line angle — more vertical lines have higher shear forces and worse fixation outcomes [21]
- FRAX Score: 10-year fracture probability calculator for secondary prevention [16-17]
- Fascia iliaca compartment block (FICB): Ultrasound-guided regional anesthesia performed in the ED; reduces pain, opioid consumption, delirium risk, and time to mobilization. The PENG block is a newer motor-sparing alternative with promising early data [27-31]
14. ECG
- Obtain in all elderly patients to evaluate for:
- Arrhythmia as a cause of syncope/fall (AF, heart block, prolonged QTc)
- Acute coronary syndrome as a fall precipitant or perioperative risk
- Baseline ECG for anesthesia planning
- Dangerous patterns: New ST changes, Brugada pattern, prolonged QTc (especially if using ondansetron or antipsychotics postoperatively)
15. Assessment
- Severity stratification: Displaced (Garden III–IV) vs. nondisplaced (Garden I–II) is the most important distinction — displaced fractures in patients ≥65 years are best treated with arthroplasty; nondisplaced fractures may be treated with internal fixation [20]
- Typical presentation: Elderly woman after a ground-level fall with groin pain, inability to bear weight, and a shortened/externally rotated limb [1]
- Atypical presentation: Nondisplaced fracture with ambulatory patient and normal-appearing radiographs — maintain high suspicion and obtain advanced imaging [14][23]
- Complications: Avascular necrosis (up to 9.7% after internal fixation of displaced fractures), nonunion (18.5%), VTE, delirium (22–44%), surgical site infection, periprosthetic fracture [15][20][32]
- 1-year mortality: ~30%; 30-day mortality ~10% even with optimal care [1-2]
16. Treatment Plan
ED Stabilization
- Pain management: Fascia iliaca or femoral nerve block (preferred) + acetaminophen ± low-dose IV opioid [27-28]
- Immobilize the affected limb; avoid traction splints (may worsen displacement)
- IV fluids, NPO status in anticipation of surgery
- Reverse anticoagulation if indicated (vitamin K + PCC for warfarin; DOAC timing-based approach) [4-5]
Surgical Management (within 24–48 hours): [1-2][14]
Perioperative Care
- Antibiotics: Cefazolin 1–2 g IV preoperatively and for 24 hours postoperatively [1]
- Anesthesia: Spinal or general — no mortality difference [1]
- VTE prophylaxis: Pharmacologic for minimum 10–14 days (up to 35 days); aspirin is a reasonable alternative to LMWH [1][11-12]
- Transfusion threshold: Hgb <8 g/dL in asymptomatic patients [1][14]
- Delirium prevention: Multicomponent nonpharmacologic interventions (reorientation, sleep hygiene, early mobilization, hearing/vision aids, hydration, minimize opioids and anticholinergics, avoid benzodiazepines). Proactive geriatrics consultation reduces delirium incidence by 36% [13][33-35]
- Early mobilization and weight-bearing within 24 hours postoperatively [1]
17. Disposition
- All confirmed hip fractures require admission for surgical management [1][14]
- Nonoperative management: Only for patients who are nonambulatory, severely debilitated, or have end-stage terminal illness — requires shared decision-making [1]
- Orthopaedic consultation: Immediate upon diagnosis
- Orthogeriatrics/hospitalist co-management: Strongly recommended — interdisciplinary care decreases complications and improves outcomes (AAOS strong recommendation) [14]
- Suspected occult fracture with negative radiographs: Admit for advanced imaging (CT → MRI if CT negative) or ensure close outpatient follow-up within 24–48 hours with strict non-weight-bearing and return precautions [14][23]
- Postoperative disposition: Inpatient rehabilitation or skilled nursing facility for most elderly patients; discharge home if adequate support and functional recovery
18. Follow Up / Return Precautions
- Postoperative follow-up: Orthopaedic follow-up at 2 weeks (wound check), 6 weeks, 3 months, and 1 year
- Osteoporosis evaluation and treatment: Initiate bisphosphonate therapy (or alternative) unless contraindicated — typically started 2 weeks postoperatively [1][16]
- Fall prevention: Home safety assessment, physical therapy, medication review to deprescribe FRIDs, vision correction [1][7]
- Return precautions (patient counseling):
- Increasing pain, swelling, redness, or drainage at the surgical site
- Fever >101°F (38.3°C)
- Calf pain/swelling or sudden shortness of breath (VTE symptoms)
- New confusion or altered mental status
- Inability to bear weight as instructed
- Expected recovery: Most patients regain functional mobility within 3–6 months; however, only ~40–60% return to pre-fracture functional level. Rehabilitation is critical to long-term outcomes [1]
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