Executive Editor: Joseph Schatzker, Peter Trafton

Authors: Ernst Raaymakers, Inger Schipper, Rogier Simmermacher, Chris van der Werken

Proximal femur - Femoral neck fracture, subcapital, undisplaced or impacted

back to skeleton

Glossary

General considerations

Neck fractures are extraarticular but intracapsular; the articular surface is not damaged, but the blood supply to the femoral head may be compromised.

In subcapital fractures with only slight displacement or impaction there is a significant risk that the fracture will displace. For this reason, most of these fractures are stabilized with screws. Nonoperative treatment is usually only considered for patients who are unfit for surgery.

Nonoperative treatment
Main indication Skill Equipment
Patients unfit for surgery; severe soft-tissue problems Basic surgical experience, no specialized skills Basic equipment only

In 50% of cases, subcapital fractures heal without any treatment. The choice of method is a question of ethics and philosophy.
Bed rest is advised as long as pain persists.

Indications

  • Non-ambulatory patients 
  • Severe soft-tissue problems in surgical area (pressure sores, acute infection, etc) 
  • Patients willing and able to risk fracture displacement

Contraindications

  • Unwillingness to accept risk of fracture displacement

Advantages

  • No surgical or anesthetic risks

Disadvantages

  • 30-50% risk of secondary displacement 
  • Activity limitation to protect from displacement
MIO - Cancellous screws
Main indication Skill Equipment
All subcapital fractures; patients unable to protect their hip Some specialized surgical experience Simple surgical and imaging resources

Internal fixation without reduction - Do not reduce an impacted fracture!

Indication

  • Unwillingness to accept risk of fracture displacement

Contraindications

  • Severe soft-tissue problems in surgical area (pressure sores, acute infection, etc) 
  • Extremely high-risk patient (significant comorbidities) 
  • Non-ambulatory patients

Advantages

  • Less risk of secondary displacement (0-13%) 
  • Earlier return to activities of daily living

Disadvantages

  • Risk of surgical complications, including fractures through screw holes 
  • Many patients (perhaps 50%) will do well without operation
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2010-11-14