Dr. Ebraheim’s educational animated video describes femoral neck fractures in the elderly patient.
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Femoral Neck Fracture in the Elderly Patient
Femoral neck fracture in the elderly patient is an important topic because it is connected to osteoporosis and to the high mortality rate in the elderly. In the hospital, the mortality rate is about 6%. The mortality rate in one year is about 25%. Surgery is usually needed to treat patients with femoral neck fractures. Very rarely the patient is treated without surgery and that can occur in patients with serious, significant medical issues. There is consensus that surgery should be done early and the outcome is better when the surgery is done within 48 hours of admission. Surgery is usually done once the medical condition of the patient is optimized. Sicker patients are usually admitted under the medical service. Younger, healthier patients are usually admitted under orthopedic care. Co-management is frequently done for these patients. Sometimes screening Doppler is done in delayed presentation to the hospital to diagnose DVT and to document its presence on admission that it occurred before the patient came to the hospital and that it is not a hospital acquired condition. While it is a clear cut or straight forward decision to save the femoral head in the younger patient and to do reduction (closed or open), this decision is variable in the elderly patient. This decision usually depends on the displacement of the fracture and the physiologic condition of the patient. The physiologic age of the patient determines the treatment and the risk of complication. The pre-injury cognitive and physiologic age and function determines the optimal function after hip fracture treatment. There is a consensus that if the fracture is nondisplaced, complete or incomplete fracture, then you will treat the fracture with screw fixation. Usually at least three screws are used. The surgery is a relatively small surgery. Do not use screws for displaced femoral neck fractures in the elderly patient. The rate of failure and reoperation rate is high for this group of patients. The type of anesthesia given to the patient is variable. It can be general or spinal anesthesia. If the fracture is displaced and unstable, then you will do hemiarthroplasty. Cemented is probably better than cementless. Cementless procedure may cause intraoperative fractures. Unipolar or bipolar procedures are controversial, however they have similar outcomes. There is no difference between bipolar and unipolar procedure except the cost (bipolar procedure is more expensive). This procedure (the prosthesis) is usually done in a patient that is physiologically old. However, total hip arthroplasty can also be done in these patients. Total hip arthroplasty is usually done in a patient with a previous hip disease or it can also be done in the older patient that is active or physiologically young. Total hip arthroplasty is usually done in a patient with a previous hip disease or it can also be done in the older patient that is active or physiologically young. Total hip will have an increased risk of dislocation. Which approach the physician will use to do the procedure is controversial. The anterolateral approach will give more fractures and abductor weakness. The posterior approach will give increased incidence of posterior dislocations and there is a need for excellent posterior capsular repair to reduce the incidence of dislocations. In general, the trend is to do cemented hemiarthroplasty.
