Femoral Neck Fractures
Posted: Monday, May 18, 2009
by Jonathan Blood Smyth
Fractured neck of femur patients take up significant numbers of beds in hospitals in all the developed nations, as elderly people develop low bone density, especially women after the menopause. Less commonly stress fractures can occur in anyone who puts greatly increased stresses through their hips such as running athletes and soldiers who are in a much younger age group. Trauma such as a fall onto the side of the hip can cause this fracture in almost any age group as can pathological conditions in the area secondary to tumours.
The neck of the femur is vulnerable to the stresses, both shearing and compressive, which occur in walking and in highly amplified levels in athletic events such as running, jumping and other high performance activities. Forces across the hip can reach five to six times the person's bodyweight in certain cases and these stresses can cause bony changes. Typical hip pain occurs in the hip, the groin and the front of the thigh and can be caused by many hip problems apart from stress fracture. Stress fractures can progress to a complete fracture with possible displacement and all the potential consequences.
If abnormally increased levels of stress are imposed on normal bone by a healthy individual the bony trabeculae which resist mechanical forces can fail and the result is a stress fracture. In older women after the menopause the bone is abnormal due to pathological insufficiency from metabolic conditions or osteoporosis and in this case normal mechanical stresses can be too much for the bony structures. Bone health and turnover are maintained by oestrogen levels and once the hormonal levels drop bone develops brittleness, both in female sportspeople who train very highly or in older females.
A specialist will consider stress fracture in the differential diagnosis of an athlete who, after an increase in training, presents with a new hip pain problem. The pain is generally worse with the sport and better with resting. Bone scanning is a more sensitive investigation than x-rays in this case. The vast majority of these fractures occur in elderly persons who fall or twist, fracturing the femoral neck. Diagnosis is established by noting an inability to stand on the leg, a laterally rotated leg, a shortened limb and pain in the side of the hip and the groin.
Displacement of transverse femoral neck fractures occurs in ten to fifteen percent of cases and avascular necrosis is a risk in these injuries. Operative management is the necessary option and the choice of the technique depends on the fracture. Fractures occur in many positions anatomically and are grouped into categories, with fractures just below the head carrying the highest risk of circulatory disturbance. These are managed either by Thompson hemi-arthroplasty or by total hip replacement. Fractures in the neck can be internally fixed.
It is common for femoral neck fractures to be undisplaced and compacted, in other words the fragments have been compressed together and are stable under load. This makes conservative rather than surgical management more appropriate. Other fractures are mechanically unstable because they are under tension of the fragments to separate and displace, needing surgical fixation with one of many devices for upper femoral fixation. Trochanteric, sub-trochanteric and lower neck fractures can come more commonly into this category.
Once the fracture is replaced or fixed the patient is allowed 24 hours to recover medically then the physiotherapist and an assistant will check the operative instructions, review the patient's observations and get the patient up weight bearing with a frame or crutches.
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, physiotherapists in Leeds, back pain, musculo-skeletal conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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