Print Friendly, PDF & Email

Hip Fractures: Intracapsular Neck of Femur Fractures



Definition of an intracapsular neck of femur fracture (#NOF)

  • Intracapsular neck of femur fractures (#NOF)  occur within the capsule of the hip joint
  • The blood supply to femoral head travels in a retrograde direction via the capsule. As such, any fracture within the capsule could be likely to damage this blood supply (see below, complications)


Epidemiology of intracapsular neck of femur fractures

  • The classic patient is an elderly female with a low body mass index
    • This is an example of an insufficiency fracture and therefore most likely to occur in those with other comorbidities
  • In young patients this is more often the result of high energy trauma such as road traffic accidents or falls from a height.
    • As such ATLS principles and investigation for coexisting injury must occur in these patients


Types of hip fracture

Types of hip fracture


Risk factors for neck of femur fractures

  • The commonest cause in the elderly is generally a fall onto the side of the fracture
  • The primary risk factors is osteoporosis but also other age-related issues which might make a frail patient likely to fall (i.e. poor vision, poor proprioception, arthritis, dementia)


Presentation of neck of femur fractures

  • Fall followed by pain in the groin with referred pain to the thigh
  • Limited ability to weight bear
  • Limited range of movement (particularly straight leg raise)
  • External rotation with shortening of the limb length in displaced fractures



Differential diagnosis of intracapsular neck of femur fractures

  • Extracapsular neck of femur fractures
  • Severe osteoarthritis of the hip/fracture osteophytes
  • Femoral shaft fractures
  • Acetabular/pelvic fractures (including pubic symphysis fractures)
  • Septic arthritis of the hip
  • Radicular pain from spinal pathology
  • Psoas abscess


Classification of intracapsular neck of femur fractures

  • The most common classification is the Garden classification:
    • Garden I: incomplete and undisplaced fracture
    • Garden II: Complete but undisplaced fracture
    • Garden III: Complete fracture with partial displacement
    • Garden IV: Complete fracture with 100% displacement


Garden classification of hip fractures

Types of neck of femur fracture (Garden classification)


Initial management of intracapsular neck of femur fractures

  • ABC approach
    • Bloods, including clotting and G&S
    • Fluids +/- RBC if shocked (a lot of blood can be lost into the hip following fracture)
  • AP and lateral radiographs of the pelvis and affected hip
    • Full length femur radiographs should be obtained if there is any suspicion of a pathological fracture (such as malignancy)
  • Once fracture determined
    • Po analgesia +/- a fascia iliaca block
    • Discuss with the orthopaedic on call team


Further management of intracapsular neck of femur fractures

  • This depends on the performance status of the patient as well as the displacement of the fracture
  • Non-displaced fractures (Garden I+II)
    • Relatively young patients (either chronologically or more important, physiologically) should have urgent internal fixation via 3 or 4 parallel partially threaded cancellous screws
  • Displaced fractures (Garden III+IV), or even non-displaced fractures in the context of patients unlikely to tolerate non-weight bearing
    • Replacement of the femoral head to obviate the risks of avascular necrosis (see below)
    • This is most often via a hemiarthroplasty
      • Younger, fitter patients are being offer a primary total hip replacement (THR) in centres able to provide the service


Complications following intracapsular neck of femur fractures

  • General risks
    • Anaesthetic risks
    • Blood loss in theatre
    • Venous thromboembolic disease
      • Give anticoagulation +/- thromboembolic prevention stockings as per local protocol
  • Internal fixation
    • Avascular necrosis
    • Mal-union or non-union of the fracture
    • Infection of metalwork

·        Hemiarthroplasty

    • Dislocation of prosthesis
    • Peri-prosthetic fractures
    • Metalwork  failure or acetabular erosion and consequent need for revision


Prognosis of intracapsular neck of femur fractures

  • The presence of a hip fracture increase mortality for the first year
  • After this period and levels return back to near normal


Click here for medical student OSCE and PACES questions about Hip Fractures: Intracapsular Neck of Femur Fractures

Common Hip Fractures: Intracapsular Neck of Femur Fractures  exam questions for medical students, finals, OSCEs and MRCP PACES


Click here to download free teaching notes on Hip Fractures (#NOF): Intrcapsular Neck of Femur Fractures

Perfect revision for medical students, finals, OSCEs and MRCP PACES