Executive Editor: Joseph Schatzker, Peter Trafton

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

Proximal femur - Femoral neck fracture, transcervical or basicervical

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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.

For transcervical fractures there is still some debate about the relative merits of fixation vs arthroplasty, and which are the best indications for each.

A sliding hip screw should be preferred over multiple smaller screws, if intrinsic stability is questionable, particularly in osteoporotic bone, or in case of a comminuted fracture.

MIO - Cancellous screws
Main indication Skill Equipment
Pauwels type I-II fractures, good bone quality Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Physiologically younger patients with Pauwels I and II  fractures (see note below), good bone quality, and a jagged fracture line 
  • Rarely, if ever, for Pauwels type III fractures (see note below)
  • Ability to achieve anatomic closed reduction 
  • Ambulatory patients

Contraindications

  • Unreduced fracture 
  • Significantly unstable fractures (Pauwels type III, comminution, poor bone quality)
  • Inability to achieve anatomic closed reduction 
  • Preexisting hip arthritis 
  • Physiologically older patient with unstable fracture
  • Non-ambulatory patients 
  • Severe soft-tissue problems in surgical area (pressure sores, acute infection, etc) 
  • Patients not fit for surgery

Advantages

  • Minimal soft-tissue exposure and blood loss 
  • May provide adequate stability, particularly with favorable fracture pattern and bone quality
  • Fixation is usually straightforward 
  • Healed fracture with normal alignment usually provides best result

Disadvantages

  • Requires a stable (near anatomical) reduction and stable fracture
  • Risk of secondary displacement 
  • Risk of avascular necrosis
  • 10% nonunion
  • Risks of surgery

Note: The Pauwels classification can best be determined intraoperatively, once traction is applied, and the fracture is reduced. After this, choice of fixation is easier. On an AP fluoroscopic view, assess the inclination of the fracture line. Pauwels type I is a fracture with <30º from the horizontal. Type II is 30º-70º from the horizontal. Type III is >70º from the horizontal.

MIO - Sliding hip screw
Main indication Skill Equipment
Pauwels type II-III fractures, osteoporosis, comminution Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Most transcervical fractures in physiologically younger patients, particularly if intrinsic stability is questionable (Pauwels type III or II (see note below), osteoporosis, comminution)
  • Ability to achieve anatomic closed reduction 
  • Preferable to arthroplasty, unless severe osteoporosis
  • Ambulatory patients

Contraindications

  • Inability to achieve anatomic closed reduction 
  • Significantly unstable fractures 
  • Physiologically older patient (arthroplasty candidate)
  • Preexisting hip arthritis 
  • Non-ambulatory patients 
  • Severe soft-tissue problems in surgical area (pressure sores, acute infection, etc.) 
  • Patients not fit for surgery

Advantages

  • May be more stable than multiple screws 
  • Minimal soft-tissue exposure and blood loss 
  • May provide adequate stability, particularly with favorable fracture pattern and bone quality
  • Fixation is usually straightforward 
  • Healed fracture with normal alignment usually provides best result

Disadvantages

  • Requires a satisfactory reduction 
  • Requires a supplementary screw for rotational stability 
  • Prominent implant may be painful
  • Risk of secondary displacement 
  • Avascular necrosis
  • 10% nonunion
  • Risks of surgery

Note: The Pauwels classification can best be determined intraoperatively, once traction is applied, and the fracture is reduced. After this, choice of fixation is easier. On an AP fluoroscopic view, assess the inclination of the fracture line. Pauwels type I is a fracture with <30º from the horizontal. Type II is 30º-70º from the horizontal. Type III is >70º from the horizontal.

ORIF - Cancellous screws
Main indication Skill Equipment
Failure of closed reduction; Pauwels type I-II fractures, good bone quality Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Inability to achieve satisfactory closed reduction 
  • Physiologically younger patients with Pauwels I and II fractures (see note below), good bone quality, and a jagged fracture line 
  • Rarely, if ever, for Pauwels type III fractures (see note below)
  • Ambulatory patients

Contraindications

  • Significantly unstable fractures (Pauwels type III, comminution, poor bone quality)
  • Patient not fit for surgery
  • Preexisting hip arthritis 
  • Non-ambulatory patients 
  • Severe soft-tissue problems in surgical area (pressure sores, acute infection, etc.)

Advantages

  • May provide adequate stability, particularly with favorable fracture pattern and bone quality
  • Healed fracture with normal alignment usually provides best result

Disadvantages

  • Requires a stable (near anatomical) reduction and stable fracture
  • Higher risk of infection 
  • Risk of secondary displacement 
  • Increased risk of avascular necrosis 
  • 10% nonunion
  • Risks of surgery 
  • Possibility of failure (nonunion, secondary displacement, malunion, and avascular necrosis; failed arthroplasty)

Note: The Pauwels classification can best be determined intraoperatively, once traction is applied, and the fracture is reduced. After this, choice of fixation is easier. On an AP fluoroscopic view, assess the inclination of the fracture line. Pauwels type I is a fracture with <30º from the horizontal. Type II is 30º-70º from the horizontal. Type III is >70º from the horizontal.

ORIF - Sliding hip screw
Main indication Skill Equipment
Failure of closed reduction; Pauwels type II-III fractures, osteoporosis, comminution Basic surgical experience, no specialized skills Full specialized surgical and imaging resources

Indications

  • Inability to achieve satisfactory closed reduction 
  • Most transcervical fractures, particularly if intrinsic stability is questionable (Pauwels type III or II (see note below))
  • Ambulatory patients

Contraindications

  • Significantly unstable fractures 
  • Physiologically older patient (arthroplasty candidate)
  • Patient not fit for surgery
  • Preexisting hip arthritis 
  • Severe soft-tissue problems in surgical area (pressure sores, acute infection, etc) 
  • Non-ambulatory patients

Advantages

  • May be more stable than multiple screws 
  • May provide adequate stability, particularly with favorable fracture pattern and bone quality
  • Fixation is usually straightforward 
  • Healed fracture with normal alignment usually provides best result

Disadvantages

  • Requires a satisfactory reduction 
  • Requires a supplementary screw for rotational stability 
  • Prominent implant may be painful
  • Higher risk of infection 
  • Risk of secondary displacement 
  • Increased risk of avascular necrosis 
  • 10% nonunion
  • Risks of surgery

Note: The Pauwels classification can best be determined intraoperatively, once traction is applied, and the fracture is reduced. After this, choice of fixation is easier. On an AP fluoroscopic view, assess the inclination of the fracture line. Pauwels type I is a fracture with <30º from the horizontal. Type II is 30º-70º from the horizontal. Type III is >70º from the horizontal.

Arthroplasty
Main indication Skill Equipment
Surgeon or local preference; older patient or irreducible fracture Some specialized surgical experience Simple surgical and imaging resources

Indications

  • Physiologically older patients 
  • Preexisting hip arthritis 
  • Unsatisfactory reduction in older patient
  • Ambulatory patients

Contraindications

  • Physiologically younger patient with good quality bone and stable fracture pattern
  • Non-ambulatory patients 
  • Severe soft-tissue problems in surgical area (pressure sores, acute infection, etc) 
  • Patient not fit for surgery

Advantages

  • No risk of secondary displacement
  • No risk of avascular necrosis
  • Immediate full weight bearing possible
  • Good chance of long-term function

Disadvantages

  • Relatively major operation 
  • Risks of surgery 
  • Complications of arthroplasty

Note: Hemiarthroplasty is quicker, cheaper and has a lower risk of dislocation than total joint replacement, but may lead to acetabular pain and erosion, requiring revision surgery at a later date. Uncemented stems are becoming more popular, and the published literature suggests a similar outcome to cemented stems, but in inexperienced hands there may be an increased risk of peroperative fracture as an uncmented stem is impacted into an osteoporotic femur.

*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