An Acta Orthopaedica educational article: Femoral neck fractures in adults with emphasis on surgical treatment

Abstract

Femoral neck fractures (FNFs) are associated with loss of function in all ages and excess mortality. The societal costs are high. Treatment needs to be tailored based on fracture type, functional demand, and physiological age of the patient. Internal fixation is often preferred for undisplaced FNFs and for displaced FNFs in young patients. Anatomical reduction is essential, but slight valgus is accepted. For a majority of those with displaced FNFs, a cemented hemiarthroplasty is the best alternative. This educational article suggests a treatment algorithm for FNFs and describes the evidence base for the recommended surgical techniques. Basicervical fractures, stress and pathological fractures are not included in this review.

Figure 1

The Garden classification describing the displacement of the fracture based on the anteroposterior radiograph. Garden I is valgus-impacted, Garden II is the undisplaced fracture, Garden III is varus malaligned, and Garden IV is a displaced fracture (Illustration P Andersson).

Figure 2

Preoperative anterior-posterior and lateral radiographs of undisplaced femoral neck fracture. The posterior tilt is measured as the angle (α) between mid-collum line (MCL), a line in the center of the femoral neck, and the radius collum line (RCL), a line from the center of the femoral head to the crossing of the femoral head circle and the MCL (Illustration and measurement method from Palm et al. [9]).

Figure 3

The Pauwels classification describing the shear angle of the fracture based on the anteroposterior radiograph [9] (Illustration P Andersson).

Figure 4

The 2018 AO/OTA system for classifying femoral neck fractures based on location [10] (Illustration P Andersson).

Figure 5

Patients and surgeons should consider both age and activity level when deciding on the surgical method of displaced FNFs. In areas where the methods overlap, the skills of the surgeon and of the team can also influence the choice, and shared decision-making is advocated when possible (Illustration P Andersson).