Femoral Neck Fracture

What Your Doctor May Not Tell You About Hip and Knee Replacement Surgery
by Ronald P. Grelsamer, M.D.

(Page 4 of 6)

“People come into this world under the brim of the pelvis and leave it by the neck of the femur.”

This is a medical adage that goes back many centuries, as hip fractures were terminal events until the advent of surgery. An older person immobilized by the pain of a hip fracture would develop bedsores, pneumonia, or urinary infections, and die. Thus, the primary goal of hip fracture surgery is to save the person's life. The second goal is to allow the patient to walk again. The third goal is to restore the patient to her prior level of function.

Sometimes a family will be disappointed that Grandma isn't good as new. But if she's alive, let alone walking, she's already benefited from one of the miracles of modern medicine.

When a person sustains a hip fracture, you can quibble about whether she fell and broke her hip or vice versa. The most current thinking is that most of the time the impact against the ground causes the fracture. In fact, padded girdles exist that may minimize the risk of such a fracture, but they are neither widely available nor prescribed. There are issues of cost (who will pay for such a device?), acceptance (no one likes to think of themselves as being so old and frail that they need to wear padded protection around both hips), and effectiveness (no study has demonstrated the exact extent to which these pads prevent fractures). From an orthopedic point of view, whether the fall or the fracture comes first is irrelevant-the result is the same.

A hip fracture is a fracture of the upper portion of the femur. American orthopedic surgeons (aka orthopedists) treat 250,000 of these per year, and the numbers will increase as Baby Boomers discover about ten years from now that marijuana expands the mind but not the bone.

A hip can break in one of three places: the femoral neck, the intertrochanteric area, or the subtrochanteric region. Each type of fracture presents the surgeon with a different set of challenges. The intertrochanteric and the subtrochanteric fractures are fixed with plates, screws, or rods, the so-called open reduction and internal fixation, abbreviated ORIF. These procedures range from simple to maddeningly complex. The femoral neck fractures are a breed apart. The femoral neck is a narrow structure with relatively little soft, cancellous, healing type of bone. Therefore, it is at risk for a nonunion, a fracture that refuses to heal. Fractures of the femoral neck are also associated with the potential disruption of the blood vessels supplying the femoral head. Fractures of the femoral neck are, therefore, associated with a condition called osteonecrosis, whereby a section of bone loses its blood supply and dies.

Faced with a femoral neck fracture, the orthopedic surgeon has two choices: Fix it or replace it. Fixing it means putting the pieces back together and stabilizing them (keeping them from moving) with orthopedic screws. Replacement simply means that the surgeon removes the femoral head along with the broken neck to which it is attached.

Within the world of hip replacements, the surgeon has two further options to choose from. He may perform a total hip replacement, or he may perform the hemiarthroplasty (partial replacement) described above.

Fixation of a femoral neck fracture. The advantage of fixing such a fracture is that once the fracture has healed-and assuming that no osteonecrosis develops-you are good as new. It's as if the fracture never occurred.

Of course, there are exceptions. Older patients are frequently knocked down a peg even with perfect healing of their fracture. If they were excellent walkers prior to the injury and surgery, they are now good walkers. Good walkers become fair walkers, etc. But younger patients are often close to being good as new. Once the fracture has healed, there are no restrictions on activities. True, the screws or plate may need to be removed one day (mostly in younger patients), and this will require a period of crutch walking, but those restrictions are temporary.

The three downsides to fixing a femoral neck fracture are that (1) you may need to use crutches for six to twelve weeks, (2) the bone may not heal, and (3) the femoral head may go on to osteonecrosis. The last two scenarios require a trip back to the operating room for a hip replacement.

Copyright © 2004 by Ronald Grelsamer, M.D.

About the Author

RONALD P. GRELSAMER, M.D., is the chief of hip and knee reconstruction at Maimonides Medical Center, and a staff orthopaedic surgeon at the NYU Hospital for Joint Diseases/Orthopaedic Institute.