Anteroposterior radiograph showing a valgus-impacted femoral neck fracture in a 76-year-old woman
Lateral radiograph of the patient’s left hip
A 76-year-old woman presents with severe left hip pain after a fall at home. She was unable to get off the floor after the fall and was brought to the emergency department by emergency medical services. Upon examination, the patient has severe pain with passive motion of the left hip. There is no shortening or deformity of the left lower extremity. A valgus-impacted femoral neck fracture is noted on both anteroposterior and lateral x-rays.
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As the population ages, hip fractures are becoming an increasingly common presentation in emergency rooms. Among the elderly, low-energy falls that result in a fracture are most often the result of osteoporosis or poor bone quality. The expected increase in osteoporotic-related fractures is particularly concerning, as hip fractures alone carry up to a 25% mortality rate within the first year.1
The Garden classification system is commonly used to describe and determine treatment of femoral neck fractures. The classification system has 4 types: type 1 includes incomplete fractures (fracture line partially through the femoral neck) or valgus-impacted fractures; type 2 includes nondisplaced fractures; type 3 includes complete fractures (fracture line crosses the entire femoral neck) with partial displacement; and type 4 includes completely displaced fractures.
For treatment purposes, the classification system can be simplified into 2 categories. Stable nondisplaced or valgus-impacted fractures (Garden types 1 and 2) are generally treated with cannulated screw fixation. Unstable displaced fractures (Garden types 3 and 4) are generally treated with arthroplasty. Displaced fractures disrupt the hip capsule and blood supply to the femoral neck. The resulting poor blood supply to the femoral neck causes a high incidence of nonunion and osteonecrosis, and therefore, the femoral head will not heal and must be replaced with a prosthesis. Prompt recognition and treatment of these fractures is known to improve patient outcomes. Patients should be taken to surgery as soon as they are medically stable to benefit from early mobilization.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Blomberg J. Femoral neck fractures. Orthobullets website. http://www.orthobullets.com/trauma/1037/femoral-neck-fractures. Updated July 11, 2016. Accessed July 12, 2016.
- Koval KJ, Zuckerman JD. Hip Fractures: I. Overview and evaluation and treatment of femoral-neck fractures. J Am Acad Orthop Sur. 1994;2(3):141-149.