Hip fractures

Femoral neck fracture

• Clinical features
  • Groin pain
  • Shortened and externally rotated leg

Feature	Femoral Neck Fracture	Posterior Hip Dislocation
Classic Patient	Elderly (osteoporosis) after a fall.	Young patient after major trauma (MVA).
Limb Position	Shortened & EXTERNALLY Rotated.	Shortened & INTERNALLY Rotated.
Key Complication	Avascular Necrosis (AVN) of femoral head.	Sciatic Nerve Injury; AVN if reduction is delayed.
Management	Surgical Repair/Replacement (ORIF or Arthroplasty).	Emergent Closed Reduction (<6 hours).

Feature	Intertrochanteric Fx	Femoral Neck Fx
Location	Extracapsular	Intracapsular
Blood Supply	Good	Tenuous (Medial Femoral Circumflex a.)
Hallmark Risk	Malunion	Avascular Necrosis (AVN)
Typical Tx	ORIF (Dynamic Hip Screw)	Arthroplasty (in elderly)
Presentation	Leg shortened & externally rotated	Leg shortened & externally rotated (often less severe, capsule limits the degree)

Management

• Preoperative Stabilization:
  • Surgical Timing: Goal is definitive repair within 24–48 hours (reduces 30-day and 1-year mortality, pressure ulcers, and pneumonia).
  • Analgesia: Multimodal (IV acetaminophen, low-dose opioids); regional nerve blocks (e.g., fascia iliaca block, femoral nerve block) reduce delirium and opioid requirements.
  • Medical Optimization: Correct active electrolyte imbalances, reverse urgent anticoagulation (e.g., vitamin K, 4F-PCC, idarucizumab, andexanet alfa), manage cardiac instability.
• Surgical Repair (by Anatomic Location):
  • Femoral Neck Fractures (Intracapsular):
    • Displaced (Elderly): Hemiarthroplasty or Total Hip Arthroplasty (THA) (avoids high nonunion/AVN risk).
    • Nondisplaced (Elderly): Percutaneous cannulated screw fixation.
    • Young/Active Patients: Urgent Open/Closed Reduction and Internal Fixation (ORIF) to attempt femoral head preservation.
  • Intertrochanteric Fractures (Extracapsular):
    • Intramedullary (Cephalomedullary) Nail or Dynamic Sliding Hip Screw (DHS).
  • Subtrochanteric Fractures:
    • Cephalomedullary Nail with long intramedullary rod.
• Postoperative Care & Secondary Prevention:
  • Early Mobilization: Out of bed and weight-bearing within 24 hours post-op.
  • VTE Prophylaxis: Pharmacologic (LMWH, fondaparinux, or direct oral anticoagulants) for a minimum of 10–14 days (extended prophylaxis up to 35 days preferred).
  • Secondary Fracture Prevention:
    • Perform DXA scan post-discharge.
    • Initiate Bisphosphonates (e.g., alendronate, zoledronic acid) or teriparatide.
    • Calcium and Vitamin D supplementation.
    • Fall risk assessment, home safety evaluations, physical therapy.