Femoral Neck Fracture Treatment & Management

Rehabilitation program

Physical therapy

The goals of treatment in patients with femoral neck fractures are to promote healing, to prevent complications, and to return function. The primary goal of fracture management is to return the patient to his or her premorbid level of function. This is completed with either surgical or nonsurgical management. Several factors must be considered before a treatment plan is recommended.

With uncomplicated fractures of the femoral neck, treatment for the athlete should focus on rest and reversing any training errors. Modifying one's risk factors is also important at this point to prevent progression of the fracture.

A physical therapist may be useful for reinforcing the physician's instructions for rest and helping the patient modify his or her training program to allow healing. The athlete can maintain physical fitness and mobility by exercising the remaining extremities and performing non–weight-bearing strengthening activities that do not cause strain on the affected hip joint. The physical therapist can evaluate the patient for any gait or anatomic abnormalities that may have predisposed the patient to development of the fracture. Some patients may need orthotics to prevent excessive pronation, which causes increased stress on the femoral neck. The physical therapist completes patient education throughout the rehabilitation process, whether surgical or nonsurgical treatment is rendered.

Medical issues/complications

A patient's medical condition must be considered when considering surgical repairs of femoral neck fractures. If the nonoperative approach is taken, the patient should be mobilized as soon as possible to avoid the complications of prolonged immobilization.

Most complications are associated with fracture displacement or a delay in diagnosis. Complications include delayed union, nonunion, refracture, osteonecrosis, and avascular necrosis. Early fixation failure (within 3 months of surgery) occurs in 12-24% of displaced femoral neck fractures treated by internal fixation. Dai et al reported that the most common complications in children who were surgically treated for femoral neck fracture were avascular necrosis, nonunion of fracture, coxa vara, and premature physeal closure. ^[19]

In a long-term study that followed elderly patients treated with internal fixation, Blomfeldt et al reported a hip complication rate of 42% and a reoperation rate of 47% at 48 months. ^[20] Stappaerts found that the most important factors associated with loss of fixation were advanced age and inaccurate reduction. ^[21]

Scheck emphasized the importance of posterior comminution of the femoral neck as a cause of fixation failure and nonunion. ^[22] Additionally, Heetveld et al reported that no difference was noted between osteopenic and osteoporotic patients treated with internal fixation when considering revision to arthroplasty. ^[23]

Surgical intervention

The decision for operative or nonoperative treatment of femoral neck fractures and the decision regarding the type of surgical intervention are based on many factors. ^[24] This article does not address all these issues. Consultation with an orthopedist is necessary. Tension fractures are potentially unstable and may require operative stabilization. Nondisplaced femoral neck fractures may need to be stabilized with multiple parallel lag screws or pins.

The treatment of a displaced fracture is based on the person's age and activity level. In the elderly population, premorbid cognitive function, walking ability, and independence in activities of daily living should be considered when determining the optimal method of surgical repair.

Compression fractures are more stable than tension-type fractures, and they can be treated nonoperatively. Treatment for nondisplaced fractures is bed rest and/or the use of crutches until passive hip movement is pain free and x-ray films show evidence of callus formation. Patients should be monitored closely with serial x-ray films, because the risk of displacement of the fracture is high. Immediate open reduction and internal fixation is indicated if the fracture widens.

A displaced fracture in a young patient is an orthopedic emergency, and early open reduction and internal fixation is necessary. The prognosis for returning to a high level of sport participation is poor in this situation. In elderly patients, treatment options include open reduction and internal fixation or prosthetic replacement.

The decision between these options should be made on an individual basis. A series of studies by Blomfeldt et al demonstrated that total hip replacement in elderly patients with higher cognitive function and a more independent lifestyle was associated with a significantly lower complication and reoperation rate. ^[20] Additionally, health-related quality of life was superior at 2 years and equal at 4 years when compared with patients treated with internal fixation. Conversely, neither total hip replacement nor internal fixation was found to be advantageous in patients with severe cognitive impairment. Both prosthetic replacement and internal fixation were associated with a high rate of mortality and decreased functioning in activities of daily living.

In patients with an overt fracture line and no displacement on x-ray films, the initial treatment is complete non–weight-bearing ambulation with crutches. The clinician should obtain an x-ray film every 2-3 days the first week to detect any extension or widening of the fracture line. If pain does not resolve or if evidence of fracture line expansion is noted, internal fixation is indicated. In patients with a positive bone scan result and no visible fracture line on the x-ray film, the initial treatment is proportional to the severity of the symptoms. Treatment begins with non–weight-bearing or partial weight-bearing (based on symptoms) activities with crutches until symptoms resolve.

Wang et al conducted a meta-analysis of randomized controlled trials comparing the outcomes of bipolar hemiarthroplasty with total hip arthroplasty for treating femoral neck fractures in healthy elderly patients. The study concluded that for healthy elderly patients with displaced femoral neck fractures, treatment with bipolar hemiarthroplasty led to better outcomes regarding dislocation rate, while total hip arthroplasty was better regarding acetabular erosion rate and reoperation rate. ^[25]

Consultations

For high-risk fractures that require surgical intervention, consultation with an orthopedic surgeon is necessary.

Rehabilitation program

Physical therapy

Once the painful symptoms of a stable femoral neck fracture are controlled during the acute phase of treatment, strengthening exercises for the hip stabilizers and associated muscles can be initiated. The main objectives are to improve and restore range of motion of the hip.

Once the patient is pain free, weight bearing can be progressed. When patients are able to tolerate partial weight-bearing ambulation, general conditioning workouts, including swimming and cycling, are permitted. Serial x-ray films are obtained at weekly intervals until the patient can ambulate with full weight bearing and no pain.

Running is gradually reintroduced, and progression of distance is slow. If pain occurs, a couple of days of rest are recommended, mileage is reduced, and then mileage is progressed again depending on the individual's symptoms.

Surgery is indicated for patients with overt fractures or displacement on the tension side. Usually, fixation with a plate and screws is used. Postoperatively, the patient rests until pain resolves and then progresses to full activity as healing occurs. Once the plate is removed, further rehabilitation is needed. Removal of the plate depends on the age and activity level of the patient. Some patients prefer weight bearing with crutches. Patients are usually allowed to return to running; however, contact sports are limited.

Strengthening of the gluteus medius, a hip abductor, is important for postoperative stability. Other important muscles include the iliopsoas; gluteus maximus; adductor magnus, longus, and brevis; quadriceps; and hamstrings. Functional goals include normalizing the patient's gait pattern. Activities are then progressed to sport-specific training and strengthening.

Maintaining aerobic conditioning throughout the rehabilitation process is important. If protected or non–weight-bearing ambulation is necessary, then upper body exercise, such as an upper body ergometer, can be used. Once partial weight-bearing ambulation is allowed, aquatic training may be used, such as swimming or deep-water running.

Surgical intervention

Patients with overt fractures or displacement on the tension side require surgical intervention for proper healing. Generally, internal fixation is required with the use of a plate and screws.

Rehabilitation program

Physical therapy

The maintenance phase represents the final phase of the rehabilitation process in patients with femoral neck fractures. Eccentric muscle-strengthening exercises, including more dynamic conditioning exercises (eg, with a large gym ball), are added to the patient's program. In addition, sport-specific training should be incorporated so that the athlete can maintain muscle balance.