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Classification of Femoral Neck Fractures

It can be classified according to -Anatomical Location
  1. Subcapital - Fracture that occur immediately beneath the articular surface of the femoral head along the old epiphyseal plate
  2. Transcervical - Fracture pass across the femoral neck between femoral head and greater trochanter
  3. Basicervical - It is included in extracapsular inter-trochanteric fracture (not in neck femur).
  1. Fracture Angle (Pauwel’s classification)
  1. Pauwel’s angle is the angle formed by the line of fracture with the horizontal plane
    As fracture progresses from type I to type III, the obliquity of the fracture line increases and theoretically, the shear forces (distracting forces) at the fracture site also increases.
  1. Fracture Displacement (Garden Classification)
    1. It is based on degree of displacement.
    2. Displacement is judged by the abnormal shape of the bone outlines & degree of mismatch of trabecular line in femoral head, neck and the acetabulum.
  1. Undisplaced
    • Stage I
      Femoral head trabeculae are normally aligned with acetabular trabeculae but has increased valgus with neck trabeculae.
    • Stage II
      Complete fracture with full displacement
      Trabeculae are interrupted by a fracture line across the entire neck but all the three trabeculae (neck, head & acetabular) are in alignment
  2. Displaced
    • Stage III
      1. Complete fracture with partial displacement
      2. The trabecular pattern of femoral head does not line up with the acetabulum & neck.
    • Stage IV
      1. Complete fracture with full displacement
      2. There is no contact between proximal & distal fracture fragments - the proximal fragment is free and lies correctly in the acetabulum. So trabeculae of head and acetabulum are aligned but the trabeculum of head and neck are disrupted (not aligned).
  1. Clinical Features
    1. Fracture of the neck of femur are usually sustained by old people from trivial strains such as tripping on a stair or stumbling on a carpet.
    2. It most commonly occur in elderly women. Risk factors are postmenopausal/age related osteoporosis, bone losing or bone weakening disorders such as osteomalacia, diabetes, stroke (disuse), alcoholism, and chronic debilitating disease.
    3. Every elderly patient who, after trivial injury, complains of pain in the region of hip and lies with the limb in lateral rotation should be assumed to have sustained a fracture of femoral neck until radiographs taken in two planes prove other wise.
    4. In the extra capsular fractures (intertrochanteric fracture) there is usually gross deformity and loss of function but in undisplaced intracapsular (neck)fracture patient may still be able to walk, and such ordinary signs of fractures as shortening of the limb seldom develop until after several days or weeks.
    5. Quite often with minor displacement the only clinical sign that is obvious is slight lateral rotation deformity and a provisional diagnosis should be made on this evidence alone.
    6. Femoral neck fractures and intertrochanteric fractures occurs with about the same frequency. They are both more common in women than in men by a margin of three to one. More ever fracture intertrochanteric femur occurs in elderly patients even more than fractures of femoral neck itself.
  2. Mechanism Of Intracapsular Fracture Neck Femur
    1. Most Patient with femoral neck fractures are elderly females who have sustained a low energy trauma (trivial trauma).
    2. Young patients develop femoral neck fractures Via- High velocity (impact) trauma, usually resulting in a direct force along the shaft of femur with or without a rotational component.
    3. Intertrochantric fractures in younger individuals are usually the result of a high energy injury such as a motor verticle accident but 90% of intertrochantric fracture in the elderly result form a simple fall
Differences Between Fracture Neck (Intracapsular) Femur and Intertrochanteric Femur


Intracapsular Neck Fracture

Intertrochanteric Fracture

Patient profile


Patients are mole likely to be older, in poorer health and have comorbid conditions. (in comparison to neck femur).


Most common in 7th decade

Most common in 8th decade


Both fractures are more common in elderly females but males are relatively more prone to develop fracture intertrochanteric femur.

Velocity of trauma






Swelling & Ecchymosis




In scarpa’s triangle

Over greater trochanter

External rotation deformity


> 450 (lateral border of foot touching couch)


<1 inch

>1 inch

Broadening of greater trochanter




*Less lateral rotation deformity in fracture neck femur is due to attachment of capsule to the distal fracture fragment which prevents excessive rotation in acute cases.
If the initial x — rays are normal but pain persists, the patient still should be examined for a suspected femoral neck fracture (occult fracture) and MRI should be performed.
  1. Principles, Rationale and Treatment Plane Of Intracapsular Fracture Neck Femur
    1. Femoral head should not be sacrificed lightly in every fracture, particularly when the fracture is undisplaced or can be reduced accurately. Primary prosthetic replacement should be reserved for the very old or infirm, and for pathological, irreducible, or grossly comminuted fractures. (i.e. when preserving head is almost not possible).
    2. United femoral neck fracture with an intact head is better than any prosthesis and where there is a reasonable chance of good internal fixation, and accurate reduction can be obtained close reduction and internal fixation should be the treatment of choice.
    3. The two main treatment modalities are — arthroplasty (hemireplacement & THR) and reduction and internal fixation by canulated cancellus screws. The prosthetic replacement allows immediate weight bearing & eliminates chances of nonunion and avascular necrosis and in limited life expectancy reduces the chances of reoperation. But the salvage procedures become complicated if there is mechanical failure or infection.

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