Femoral neck fracture in an elderly patient case study
The case
Patient: 78‑year‑old male, retired farmer
Presenting complaint: Sudden onset right hip pain after a fall, 3 hours ago.
History of presenting illness:
- The patient was walking to the bathroom when he slipped on a wet floor and landed directly on his right side.
- Immediate severe pain in the right groin, unable to bear weight.
- No previous similar episodes.
- No loss of consciousness, head injury, or chest pain.
Past medical history:
- Hypertension for 12 years, on amlodipine 5 mg daily.
- Type 2 diabetes mellitus, on metformin 500 mg twice daily, HbA1c 7.2 % (last 3 months).
- Osteoporosis diagnosed 2 years ago, on calcium carbonate 500 mg and vitamin D3 800 IU daily.
Drug history: As above, plus occasional paracetamol for knee pain.
Allergies: No known drug allergies.
Social history:
- Lives with his wife in a single‑storey house.
- Non‑smoker, occasional alcohol (1–2 glasses of wine per week).
- No regular exercise; walks short distances with a cane.
Family history: Father died of myocardial infarction at 70 y; mother had hip fracture at 82 y.
Examination:
| Parameter | Value |
|---|---|
| General | Alert, in pain, lying supine, unable to move right lower limb |
| Vital signs | BP 148/86 mmHg, HR 92 bpm, RR 18 /min, Temp 36.8 °C, SpO₂ 97 % on room air |
| Inspection | Right lower limb appears shortened and externally rotated compared with left |
| Palpation | Tenderness over the right groin, no open wound |
| Range of motion | Active and passive hip flexion/extension limited by pain; internal rotation painful |
| Neurovascular | Dorsalis pedis pulse palpable, sensation intact in all dermatomes |
| Musculoskeletal | No other joint swelling or deformity |
| Other systems | Unremarkable |
Initial investigations:
| Test | Result |
|---|---|
| Plain anteroposterior (AP) pelvis X‑ray | Intracapsular fracture of the right femoral neck, Garden type II (incomplete, <50 % displacement) |
| Lateral hip X‑ray | Confirmed fracture line, minimal posterior displacement |
| CBC | Hb 12.4 g/dL, WBC 8.2 × 10⁹/L, Platelets 210 × 10⁹/L |
| Serum electrolytes | Na 138 mmol/L, K 4.2 mmol/L, Cl 102 mmol/L |
| Renal function | Creatinine 1.0 mg/dL, eGFR 78 mL/min/1.73 m² |
| Blood glucose (fasting) | 112 mg/dL |
| Calcium, phosphate, ALP | Ca 9.2 mg/dL, PO₄ 3.5 mg/dL, ALP 85 U/L |
| ECG | Normal sinus rhythm, no ischemia |
| Pre‑operative chest X‑ray | Clear lung fields, no cardiomegaly |
The patient is admitted to orthopaedic trauma ward, kept nil per os, and analgesia with IV paracetamol 1 g q6h and tramadol 50 mg q8h PRN.
Questions
- What is the most likely diagnosis and which clinical and radiological findings support it?
- Classify the fracture according to the Garden and AO/OTA systems and explain the prognostic significance of each classification.
- Outline the pre‑operative optimisation steps required for this patient, citing current guidelines (2023‑2024).
- Discuss the surgical management options for an intracapsular femoral neck fracture in an elderly patient, and indicate which option is most appropriate for this case, providing justification.
- List the early and late complications of femoral neck fracture fixation in the elderly and the strategies to prevent or manage them.
Answers
1. Diagnosis
Diagnosis: Intracapsular (femoral neck) fracture of the right hip, Garden type II.
Supporting clinical findings
- Sudden groin pain after low‑energy fall in an osteoporotic elderly patient.
- Inability to bear weight, typical for hip fractures.
- Physical sign of a shortened, externally rotated lower limb (classic for femoral neck fracture).
Supporting radiological findings
- AP pelvis X‑ray shows a fracture line through the femoral neck with <50 % displacement (Garden II).
- Lateral view confirms the fracture line and minimal posterior displacement.
These features together make an intracapsular femoral neck fracture the most likely diagnosis.
2. Fracture classification
| System | Category for this case | Description | Prognostic relevance |
|---|---|---|---|
| Garden | Type II | Incomplete fracture with <50 % displacement; the femoral head remains partially aligned with the shaft. | Lower risk of avascular necrosis (AVN) compared with Types III‑IV, but still a high risk in the elderly because of compromised blood supply and poor bone quality. |
| AO/OTA | 31‑B1.3 | “Basicervical” fracture: subcapital, non‑displaced, extra‑articular. | Indicates a relatively stable fracture pattern; however, in patients >65 y the risk of fixation failure is higher, influencing the choice of arthroplasty versus internal fixation. |
Why classification matters
- Garden classification predicts the likelihood of displacement after reduction and the risk of AVN.
- AO/OTA provides a uniform language for surgical planning and research; the “B1” group is amenable to either fixation or arthroplasty depending on patient factors.
3. Pre‑operative optimisation (2023‑2024 guidelines)
a. Cardiovascular assessment – According to the 2023 American College of Surgeons (ACS) Trauma Quality Programs and the 2024 British Orthopaedic Association (BOA) – NICE guidelines, all patients >65 y with hip fracture should undergo a rapid cardiac risk assessment:
- Review of antihypertensive therapy; continue amlodipine, hold ACE‑I/ARB on the day of surgery to reduce intra‑operative hypotension.
- Obtain a pre‑op ECG (already done) and, if abnormal, consider a cardiology review.
b. Glycaemic control – NICE NG38 (2023) recommends target fasting glucose 80‑130 mg/dL and random <180 mg/dL.
- Continue metformin; hold on the day of surgery if contrast is planned (not needed here).
- Initiate sliding‑scale insulin if glucose >180 mg/dL peri‑operatively.
c. Bone health optimisation – Osteoporosis treatment should be continued; calcium 1 g and vitamin D 800‑1000 IU daily are adequate.
- Consider a single dose of intravenous zoledronic acid post‑operatively if renal function permits (eGFR > 30 mL/min).
d. Anaesthetic considerations – Regional (spinal) anaesthesia is preferred for hip fracture in the elderly (NICE NG38, 2023) because it reduces pulmonary complications and postoperative delirium.
e. Thromboprophylaxis – Start low‑molecular‑weight heparin (LMWH) e.g., enoxaparin 40 mg subcutaneously once daily as soon as haemostasis is secured (within 12 h post‑op).
f. Pain control – Multimodal analgesia: scheduled paracetamol, low‑dose opioid PRN, and consider a fascia‑iliaca block pre‑operatively (recommended by 2024 AAOS guidelines).
g. Nutritional assessment – Serum albumin 3.5 g/dL is the threshold; if low, provide protein‑rich supplements.
h. Timing – Surgery should be performed within 24‑48 h of admission (BOA 2024) to reduce mortality and complications.
4. Surgical management options
| Option | Description | Indications in elderly | Advantages | Disadvantages |
|---|---|---|---|---|
| Internal fixation (IF) – multiple cannulated screws or a dynamic hip screw (DHS) | Preserves native hip; suitable for non‑displaced fractures (Garden I‑II) | Patients with good bone stock, low surgical risk, and expected compliance with weight‑bearing restrictions | Higher failure rate (10‑30 %) in >65 y due to poor bone quality; risk of AVN and non‑union | |
| Hemiarthroplasty (HA) – unipolar or bipolar prosthesis | Replaces femoral head; retains acetabulum | Displaced intracapsular fractures (Garden III‑IV) or when fixation is unlikely to succeed | Shorter operative time than total hip arthroplasty (THA); risk of acetabular erosion over time | |
| Total hip arthroplasty (THA) – cemented or cementless | Replaces both femoral head and acetabulum | Active, cognitively intact patients >65 y with displaced fractures, low‑impact lifestyle | Longer surgery, higher blood loss, higher dislocation risk, but better functional outcome |
Most appropriate option for this case: Cemented bipolar hemiarthroplasty
Justification
- Age and bone quality – 78 y with osteoporosis; fixation has a higher risk of cut‑out.
- Fracture type – Although Garden II is non‑displaced, the AO/OTA 31‑B1.3 pattern in an elderly patient still carries a substantial risk of secondary displacement.
- Functional demand – The patient is low‑activity (uses a cane), making HA a reasonable balance between surgical risk and functional outcome.
- Guideline support – BOA 2024 guideline recommends HA for patients >65 y with intracapsular fractures when the patient is not a high‑functioning candidate for THA.
- Operative considerations – Cemented stem provides immediate stability in osteoporotic bone, allowing early mobilisation (within 24 h).
5. Complications and their management
Early (within 30 days)
| Complication | Incidence in elderly | Prevention / Management |
|---|---|---|
| Surgical site infection (SSI) | 1‑3 % | Pre‑op skin antisepsis, peri‑operative IV cefazolin 2 g (or clindamycin if MRSA risk), glycaemic control, wound care. If infection occurs, debridement and targeted antibiotics. |
| Deep vein thrombosis (DVT) / pulmonary embolism (PE) | 5‑10 % without prophylaxis | LMWH started within 12 h post‑op, mechanical compression devices, early mobilisation. Treat DVT with therapeutic LMWH or DOAC. |
| Peri‑operative delirium | 15‑30 % | Adequate pain control, avoid benzodiazepines, maintain sleep‑wake cycle, early mobilisation, reorientation. Manage with low‑dose haloperidol if severe. |
| Cardiovascular events (MI, arrhythmia) | 5‑10 % | Optimise cardiac status, intra‑operative monitoring, avoid hypotension. Treat according to ACLS protocols. |
| Blood loss / anemia | Up to 15 % require transfusion | Use tranexamic acid (1 g IV before incision) as per 2023 AAOS guideline; restrict transfusion to Hb < 8 g/dL (or symptomatic). |
Late (months to years)
| Complication | Frequency | Prevention / Management |
|---|---|---|
| Avascular necrosis (AVN) of femoral head | 5‑15 % after IF; <5 % after HA | Choose HA over IF in high‑risk patients; monitor with serial radiographs; if AVN develops after IF, conversion to arthroplasty is indicated. |
| Non‑union | 5‑10 % after IF | Adequate reduction and stable fixation; if non‑union occurs, revision fixation or arthroplasty. |
| Implant failure / cut‑out | 10‑20 % after IF in osteoporotic bone | Use cemented HA; ensure proper stem positioning (neutral alignment, adequate fill). |
| Acetabular erosion (specific to HA) | 10‑20 % at 5 y | Use bipolar prosthesis; consider conversion to THA if symptomatic. |
| Post‑operative hip pain | 10‑15 % | Assess for loosening, infection, or trochanteric bursitis; treat accordingly. |
| Mortality | 10‑30 % within 1 y | Early surgery, multidisciplinary care, fall prevention programmes. |
Key preventive strategies – early surgery (<48 h), multidisciplinary orthogeriatric care, aggressive DVT prophylaxis, optimal pain control, and early weight‑bearing as tolerated.
Key learning points
- Sudden groin pain with a shortened, externally rotated limb in an elderly osteoporotic patient is pathognomonic for a femoral neck fracture.
- Garden classification predicts displacement and risk of avascular necrosis; AO/OTA provides a universal language for fracture pattern.
- Pre‑operative optimisation (cardiac, glycaemic, bone health, anaesthetic planning) must be completed within 24 h to allow surgery within the recommended 48‑hour window.
- In patients >65 y with osteoporotic bone, cemented hemiarthroplasty is often preferred over internal fixation, even for non‑displaced fractures, to reduce fixation failure.
- Early mobilisation, thromboprophylaxis, and delirium prevention are essential components of postoperative care.
- Complications such as AVN, non‑union, and implant failure are more common after internal fixation; arthroplasty mitigates many of these risks.
- Multidisciplinary orthogeriatric pathways improve functional outcomes and reduce 1‑year mortality.
Practice MCQs
1. A 78‑year‑old woman presents with a Garden II femoral neck fracture. Which of the following is the most appropriate surgical treatment according to the 2024 BOA guideline?
A. Closed reduction and percutaneous cannulated screw fixation
B. Dynamic hip screw (DHS) fixation
C. Cemented bipolar hemiarthroplasty
D. Total hip arthroplasty
Answer: C — Cemented bipolar hemiarthroplasty is recommended for elderly patients with intracapsular fractures when bone quality is poor, even if the fracture is non‑displaced, to avoid fixation failure.
2. Which of the following postoperative measures has the strongest evidence for reducing the incidence of delirium in elderly hip‑fracture patients?
A. Routine use of benzodiazepines for anxiety
B. Early mobilisation within 24 h
C. High‑dose opioid analgesia
D. Prolonged fasting until day 3
Answer: B — Early mobilisation, combined with adequate pain control and sleep hygiene, is the most effective strategy to prevent delirium (AAOS 2023 recommendation).
3. A patient with an intracapsular femoral neck fracture undergoes internal fixation with three cannulated screws. Six weeks later, radiographs show progressive collapse of the femoral head. The most likely diagnosis is:
A. Deep infection
B. Avascular necrosis
C. Heterotopic ossification
D. Periprosthetic fracture
Answer: B — Collapse of the femoral head after fixation suggests avascular necrosis, a known complication of intracapsular fractures due to disruption of the retinacular vessels.
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