Management Of Femoral Neck Fractures In Young / Middle Aged Adults

  • Dr Gupta A Department of Orthopaedics, Bombay Hospital, Indore
  • Dr Choudhari P Department of Orthopaedics, Bombay Hospital, Indore
  • Dr Nagla A Department of Orthopaedics, Bombay Hospital, Indore
Keywords: Femoral neck fracture, Middle aged patient, Capsulotomy, Surgical timing, Newer methods of fixation


Femoral neck fractures account for nearly half of all hip fractures with the vast majority occurring in elderly patients after simple falls. Currently there is sufficient evidence to support the routine use of hip replacement surgery for low demand elderly patients in all but non-displaced and valgus impacted femoral neck fractures. However, for the physiologically young / middle aged patients (40 to 65 years) preservation of the natural hip anatomy and mechanics is a priority in management because of their high functional demands especially in Indian population. The biomechanical challenges of femoral neck fixation and the vulnerability of the femoral head blood supply lead to a high incidence of non-union and osteonecrosis of the femoral head after internal fixation of displaced femoral neck fractures. Anatomic reduction and stable internal fixation are essentials in achieving the goals of treatment in this relatively young patient population. Furthermore, other management variables such as surgical timing, the role of capsulotomy and the choice of implant for fixation remain controversial. This review will focus both on the demographics and injury profile of middle aged patients with femoral neck fractures and the current methodology and evidence behind the surgical management of these injuries.


Download data is not yet available.


1. Karagas MR, Lu-Yao GL, Barrett JA, Beach ML, Baron JA. Heterogeneity of hip fracture: age, race, sex, and geographic patterns of femoral neck and trochanteric fractures among the US elderly. Am J Epidemiol. 1996;143:677–82.

2. Chammout GK, Mukka SS, Carlsson T, Neander GF, Stark AW, Skoldenberg OG. Total hip replacement versus open reduction and internal fixation of displaced femoral neck fractures: a randomized long-term follow-up study. J Bone Joint Surg Am. 2012;94:1921–8.

3. Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. J Bone Joint Surg Am. 2008;90:2254–66.

4. Girard J, Glorion C, Bonnomet F, Fron D, Migaud H. Risk factors for revision of hip arthroplasties in patients younger than 30 years. Clin Orthop Relat Res. 2011;469:1141–7.

5. Gerber C, Strehle J, Ganz R. The treatment of fractures of the femoral neck. Clin Orthop Relat Res. 1993; 292:77–86.

6. Askin SR, Bryan RS. Femoral neck fractures in young adults. Clin Orthop Relat Res. 1976;(114):259–64.

7. Yang JJ, Lin LC, Chao KH, Chuang SY, Wu CC, Yeh TT, Lian YT. Risk factors for nonunion in patients with intracapsular femoral neck fractures treated with three cannulated screws placed in either a triangle or an inverted triangle configuration. J Bone Joint Surg Am. 2013;95:61–9.

8. Karantana A, Boulton C, Bouliotis G, Shu KS, Scammell BE, Moran CG. Epidemiology & outcome of fracture of the hip in women aged 65 years & under: a cohort study. J Bone Joint Surg Br. 2011;93:658–64.

9. Talboys R, Pickup L, Chojnowski A. The management of intracapsular hip fractures in the ‘young elderly’ internal fixation or total hip replacement? Acta Orthop Belg. 2012;78:41–8.

10. Hedstrom M. Are patients with a nonunion after a femoral neck fracture more osteoporotic than others? BMD measurement before the choice of treatment? A pilot study of hip BMD and biochemical bone markers in patients with femoral neck fractures. Acta Orthop Scand. 2004;75:50–2.

11. Zlowodzki M, Brink O, Switzer J, Wingerter S, Woodall J, Petrisor BA, Kregor PJ, Bruinsma DR, Bhandari M. The effect of shortening and varus collapse of the femoral neck on function after fixation of intracapsular fracture of the hip: a multi-centre cohort study. J Bone Joint Surg Br. 2008;90:1487–94.

12. Adelani MA, Keeney JA, Palisch A, Fowler SA, Clohisy JC. Has total hip arthroplasty in patients 30 years or younger improved? A systematic review. Clin Orthop Relat Res. 2013;471:2595–601.

13. Davidovitch RI, Jordan CJ, Egol KA, Vrahas MS. Challenges in the treatment of femoral neck fractures in the nonelderly adult. J Trauma. 2010;68:236–42.

14. Al-Ani AN, Neander G, Samuelsson B, Blomfeldt R, Ekström W, Hedström M. Risk factors for osteoporosis are common in young and middle-aged patients with femoral neck fractures regardless of trauma mechanism. Acta Orthop. 2013;84:54–9.

15. Robinson CM, Court-Brown CM, McQueen MM, Christie J. Hip fractures in adults younger than 50 years of age. Epidemiology and results. Clin Orthop Relat Res. 1995;(312):238–46.

16. Xiao J, Yang XJ, Xiao XS. DSA observation of hemodynamic response of femoral head with femoral neck fracture during traction: a pilot study. J Orthop Trauma. 2012;26:407–13.

17. Sevitt S, Thompson RG. The distribution and anastomoses of arteries supplying the head and neck of the femur. J Bone Joint Surg Br. 1965;47:560–73.

18. Tornetta P, Kain MS, Creevy WR. Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Improvement with a standard protocol. J Bone Joint Surg Am. 2007;89:39–43.

19. Riemer BL, Butterfield SL, Ray RL, Daffner RH. Clandestine femoral neck fractures with ipsilateral diaphyseal fractures. J Orthop Trauma. 1993;7:443–9.

20. Wolinsky PR, Johnson KD. Ipsilateral femoral neck & shaft fractures. Clin Orthop Relat Res. 1995;(318):81–90.

21. Collinge CA, Mir H, Reddix R. Fracture morphology of high shear angle “vertical” femoral neck fractures in young adult patients. J Orthop Trauma. 2014;28:270–5.

22. Gill SK, Smith J, Fox R, Chesser TJ. Investigation of occult hip fractures: the use of CT and MRI. Scientific World J. 2013;8:303-19.

23. Garden RS. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg Br. 1961;43:647–63.

24. Van Embden D, Rhemrev SJ, Genelin F, Meylaerts SA, Roukema GR. The reliability of a simplified Garden classification for intracapsular hip fractures. Orthop Traumatol Surg Res. 2012;98:405–8.

25. Upadhyay A, Jain P, Mishra P, Maini L, Gautum VK, Dhaon BK. Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint Surg Br. 2004;86:1035–40.

26. Raaymakers EL. The non-operative treatment of impacted femoral neck fractures. Injury. 2002;33 Suppl 3:8–14.

27. Kuner EH, Lorz W, Bonnaire F. Femoral neck fractures in adults: joint sparing operations. I. Results of an AO collective study with 328 patients. Unfallchirurg. 1995;98:251–8.

28. Jain R, Koo M, Kreder HJ, Schemitsch EH, Davey JR, Mahomed NN. Comparison of early & delayed fixation of subcapital hip fractures in 60 years of age or less. J Bone Joint Surg Am. 2002;84:1605–12.

29. Karaeminogullari O, Demirors H, Atabek M, Tuncay C, Tandogan R, Ozalay M. Avascular necrosis and nonunion after osteosynthesis of femoral neck fractures: effect of fracture displacement and time to surgery. Adv Ther. 2004;21:335–42.

30. Razik F, Alexopoulos AS, El-Osta B, Connolly MJ, Brown A, Hassan S, Ravikumar K. Time to internal fixation of femoral neck fractures in patients under sixty years--does this matter in the development of osteonecrosis of femoral head? Int Orthop. 2012;36:2127–32.

31. Lowe JA, Crist BD, Bhandari M, Ferguson TA. Optimal treatment of femoral neck fractures according to patient’s physiologic age: an evidence-based review. Orthop Clin North Am. 2010;41:157–66.

32. Petrie J, Sassoon A, Haidukewych GJ. When femoral fracture fixation fails: salvage options. Bone Joint J. 2013;95-B:7–10.

33. Garden RS. Malreduction and avascular necrosis in subcapital fractures of the femur. J Bone Joint Surg Br. 1971;53:183–97.

34. Watson JR. Fracture of the neck of the femur. British J Surg.1936;23:787.

35. Molnar RB, Routt ML. Open reduction of intracapsular hip fractures using a modified Smith-Petersen surgical exposure. J Orthop Trauma. 2007;21:490–4.

36. Leadbetter GW. A treatment for fracture of the neck of the femur. J Bone Joint Surg. 1938;20:108-13.

37. Whittle P. Fractures of lower extremity. In:Cannale T, Beaty JH. Campbell’s operative orthopaedics.11th ed. Philadelphia: Mosby Elsevier. 2008. pp 2214.

38. Beck M, Siebenrock KA, Affolter B, Nötzli H, Parvizi J, Ganz R. Increased intraarticular pressure reduces blood flow to the femoral head. Clin Orthop Relat Res. 2004;(424):149–52.

39. Maruenda JI, Barrios C, Gomar-Sancho F. Intracapsular hip pressure after femoral neck fracture. Clin Orthop Relat Res. 1997;(340):172–80.

40. Zhou L, Tan J, Xu B. Treatment of femoral neck fracture with cannulated screw fixation in young adults. Zhongguo Xiufu Chongjian Waike Zazhi. 2007;21:275–7.

41. Watson A, Zhang Y, Beattie S, Page RS. Prospective randomized controlled trial comparing dynamic hip screw & screw fixation for undisplaced subcapital hip fractures. ANZ J Surg. 2013;83:679–83.

42. Bonnaire FA, Weber AT. Analysis of fracture gap changes, dynamic and static stability of different osteosynthetic procedures in the femoral neck. Injury. 2002;33 Suppl 3:C24–32.

43. Babak S, Arash A. A comparative study between multiple cannulated screws and dynamic hip screw for fixation of femoral neck in adults. Intern orthop. 2015;39:2069-71.

44. Aminian A, Gao F, Fedoriw WW, Zhang LQ, Kalainov DM, Merk BR. Vertically oriented femoral neck fractures: mechanical analysis of four fixation techniques. J Orthop Trauma. 2007;21:544–8.

45. Filipov O. Biplane double-supported screw fixation (F-technique): a method of screw fixation at osteoporotic fractures of the femoral neck. Eur J Orthop Surg Traumatol. 2011;21(7):539543.

46. Burns BH, Young RH. Early movement in the treatment of closed fractures. Lancet. 1944;243(6301):723-5.

47. Kuntscher G. Fully automatic nailing of the femoral neck. Z Orthop Ihre Grenzgeb. 1953;84(1):17- 28.

48. Von Bahr V, Syk B, Walheim G. Osteosynthesis of femoral neck fracture using screws. Acta Chir Scand. 1974;140(4):277-82.

49. Walker E, Mukherjee DP, OgdenAL, Sadasivan KK, Albright JA. A biomechanical study of simulated femoral neck fracture fixation by cannulated screws: effects of placement angle and number of screws. Am J Orthop (Belle Mead NJ). 2007;36(12): 680-4.

50. Aisns SE, Wanek-Sgaglione L. Intracapsular fractures of the femoral neck. Results of cannulated screw fixation. J Bone Joint Surg. 1994;76(12):1793–803.

51. Gjertsen JE, Vinje T, Engesaeter LB, Lie SA, Havelin LI, Furnes O, Fevang JM. Internal screw fixation compared with bipolar hemiarthroplasty for treatment of displaced femoral neck fractures in elderly patients. J Bone Joint Surg Am. 2010;92:619–28.

52. Martyn P, Hans WS: Aesculap Orthopaedics Targon® FN September, 2007.

53. Mir H, Collinge C. Application of a medial buttress plate may prevent many treatment failures seen after fixation of vertical femoral neck fractures in young adults. Med Hypotheses. 2015;84(5):429-33.

54. Mir HR, Edwards P, Sanders R, Haidukewych G. Results of cephallomedullary nail fixation for displaced intracapsular femoral neck fractures. J Orthop Trauma. 2011;25(12):714-20.

55. Avery PP, Baker RP, Walton MJ, Rooker JC, Squires B, Gargan MF, Bannister GC. Total hip replacement and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck: a seven- to ten-year follow-up report of a prospective randomised controlled trial. J Bone Joint Surg Br. 2011;93:1045–8.

56. Baker RP, Squires B, Gargan MF, Bannister GC. Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. A randomized, controlled trial. J Bone Joint Surg Am. 2006;88:2583–9.

57. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am. 2006;88:249–60.

58. Parker MJ, Pryor G, Gurusamy K. Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures: a long-term follow-up of a randomised trial. Injury. 2010;41:370–3.

59. Gillespie WJ, Walenkamp GH. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev. 2010;(3):CD000244.

60. Barrera LM, Perel P, Ker K, Cirocchi R, Farinella E, Morales Uribe CH. Thromboprophylaxis for trauma patients. Cochrane Database Syst Rev. 2013;3:CD008303.
How to Cite
Dr Gupta A, Dr Choudhari P, Dr Nagla A. Management Of Femoral Neck Fractures In Young / Middle Aged Adults. ojmpc [Internet]. 2018Dec.31 [cited 2020Oct.20];24(2):48-0. Available from:
Review Article