MINORS MANUAL
An intracapsular femoral neck fracture occurs within the hip joint capsule, affecting the neck of the femur, which connects the femoral head to the rest of the bone. These fractures are common in older adults, particularly those with osteoporosis, and usually result from minor falls.
Intracapsular fractures have a high risk of complications, such as avascular necrosis (AVN) of the femoral head and non-union, due to disruption of the blood supply to the femoral head.
Diagnosis
Diagnosis is suspected in older adults with acute hip or groin pain following a fall, and inability to bear weight on the affected leg. Clinically, the affected limb may be shortened and externally rotated.
Confirmation is done via anteroposterior and lateral X-rays of the hip. If X-rays are inconclusive, MRI may be required to detect occult fractures.
Differential Diagnosis
Pathology | Key Characteristics |
|---|---|
Intertrochanteric fracture | Affects the region between the greater and lesser trochanters; intense pain but lower risk of AVN |
Hip dislocation | Visible deformity, shortened limb, internal/external rotation, history of high-energy trauma |
Trochanteric bursitis | Lateral hip pain without severe trauma history |
Hip osteoarthritis | Chronic, progressive pain, no acute traumatic event |
Emergency Management
Initial evaluation (ABC): Ensure haemodynamic stability, especially in polytrauma patients.
Immobilisation: Immobilise the affected leg to prevent displacement and reduce pain. Keep the patient at rest until surgery.
Pain management: Administer analgesics (NSAIDs or opioids) to control acute pain.
Diagnostic imaging: Order X-rays of the pelvis and hip to confirm the fracture. Use MRI if needed for difficult-to-visualise fractures.
Complication prevention: Start prophylaxis for deep vein thrombosis, especially in immobilised patients, using low molecular weight heparin or compression devices.
Preoperative stabilisation: Ensure haemodynamic stability and optimise medical conditions before surgery, especially in older adults.
Definitive Treatment
Treatment depends on the patient’s age, bone quality, and fracture displacement:
Non-displaced or minimally displaced fractures: Managed with internal fixation using cannulated screws or a dynamic compression plate. This procedure aims to stabilise the fracture and preserve the femoral head, particularly in younger patients.
Displaced fractures in younger patients: Treated with open reduction and internal fixation (ORIF) to preserve the joint. Precise anatomic reduction is needed to maximise healing and prevent AVN.
Displaced fractures in older patients: Due to the high risk of AVN and non-union, hip replacement is typically recommended:
Hemiarthroplasty: Replaces only the femoral head.
Total hip arthroplasty: Replaces both the femoral head and acetabulum, recommended for active patients or those with good functional status.
Postoperative Rehabilitation
Postoperative rehabilitation is crucial for restoring mobility and function. Weight-bearing begins based on the type of surgery, and physical therapy is essential to restore function and prevent complications like deep vein thrombosis. Early mobilisation in older adults is critical to reduce mortality and improve postoperative quality of life.
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