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Femoral neck fractures are a common feature of particular populations of people with specific problems. Fractures of the neck of the femur are common in post-menopausal women and are secondary to a decrease in bone density. They are less common as stress fractures in people who put significantly increased forces on their hips such as runners and military personnel who are much younger and fitter. These fractures can also occur at almost any age by a direct fall on the hip with great force or if there are pathological changes in the bone such as tumours.

Orthopaedic specialists have understood for a long time the necessity to realign the fracture fragments due to the anatomy of the circulation of the femoral head carrying the risk of avascular necrosis (AVN) of the area. Avascular necrosis occurs when death of the bony area follows the cutting off of the blood supply, allowing the bone to collapse under stress, making an operation necessary. Hip immobilisation in a plaster spica was the treatment until Smith-Petersen developed his system of fracture fixation in the nineteen thirties. Further development involved adding sliding compression forces in devices such as the Richards Screw Plate.

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.

There is a ten to fifteen percent chance of transverse femoral neck fractures displacing with the consequent problems of avascular necrosis. Typically these fractures require surgical management and the orthopaedic specialist must choose the correct approach. The anatomical position of the fracture dictates the subsequent management, being either the replacement of the whole joint or internal fixation of the fracture. Sub-capital fractures, just below the femoral head, are likely to interfere with the circulation and in these cases joint replacement or Thompson hemiarthroplasty are preferred.

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.

The patient is rested for 24 hours after the operation to fix or replace their fracture to allow them to recover. Once the operative instructions have been noted and the patient’s medical condition checked, a physiotherapist and an assistant will mobilise the patient with a frame or crutches.