A fractured neck of femur (NOF) is a serious injury, especially in older people.  It is likely to be life changing and for some people life threatening.  Neck of femur fractures (NOF) are common injuries sustained by older patients who are both more likely to have unsteadiness of gait and reduced bone mineral density, predisposing to fracture. Elderly osteoporotic women are at greatest risk.

1. Femoral Neck Fractures
Dr. Niraj Kumar , Pt
Associate Professor Physiotherapy Dept.
Shri Guru Rai Institute Of Paramedical
Sciences , Dehradun
Revised: March 2016

2. The hip joint, or coxofemoral joint, is the articulation of the acetabulum of the
pelvis and the head of the femur. diarthrodial ball-and-socket joint
• Three degrees of freedom:
1. flexion/extension in the sagittal plane
2. abduction/adduction in the frontal plane
3. medial/lateral rotation in the transverse plane
There are two angulations made by the head and neck of the femur in relation
to the shaft.
 Angle of inclination:- The angle between the femoral neck and the medial side
of the femoral shaft viewed from the frontal plane is known as the angle of
inclination. This angle is greater at birth but decreases during childhood and
adolescent.
 The angle of inclination of the femur approximates 125°
• Normal range from 110° to 144° in the unimpaired adult
Anatomical factors

3.  Angle of torsion:- The angle formed between longitudinal axis of
the head, neck, and greater trochanter of the femur proximally and
the transverse axis of the femoral condyles distally, normally, this
angle is approximately 12 -15 degrees in adults.
Ranges of passive joint motion typical of the hip joint :
 Flexion 90 with the knee extended and 120° when the knee is
flexed.
Hip extension 10° to 20°
Abducted 45 to 50°
Adducted 20° to 30°
Medial and lateral rotations of the hip the typical range is 42° to
50°

4. Angle of inclination / Angle of torsion

5.  The structure of the head and neck of femur is developed for the
transmission of body weight efficiently, with minimum bone mass,
by appropriate distribution of the bony trabeculae in the neck.
 The tension trabeculae and compression trabeculae along with the
strong calcar femorale on the medial cortex of the neck of the femur
form an efficient system to withstand load bearing and torsion under
normal stresses of locomotion and weight bearing.
 In old age, osteoporosis of the region occurs. The incidence of
fracture neck of femur is higher in old age.

6. Blood supply

7. The profunda femoris artery arising from the Femoral artery
gives off medial circumflex femoral artery. This gives off
the lateral epiphyseal & superior and inferior metaphyseal
artery.
 Lateral epiphyseal artery supply the lateral 2/3 of femoral
head.
 Superior metaphyseal artery supplies superior part of
femoral neck & Inferior metaphyseal artery supplies the
inferior part of neck & adjacent part of head derived from
metaphysis.
 Medial epiphyseal artery (Obturater artery) supplies a
circumfoveal sectors of the head.

9. Blood Supply
• Lateral epiphysel artery
– terminal branch MFC artery
– predominant blood supply
to weight bearing dome of
head
• After fracture, blood
supply depends on
retinacular vessels
Images from: Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014

10. Definition:-
A fractured neck of femur (NOF) is a serious injury, especially in
older people. It is likely to be life changing and for some people
life threatening.
Neck of femur fractures (NOF) are common injuries sustained by
older patients who are both more likely to have unsteadiness of
gait and reduced bone mineral density, predisposing to fracture.
Elderly osteoporotic women are at greatest risk.

11. Aetiology : -
Common in older patients with osteoporosis or
osteomalacia
Mechanism of injury :
Due to trivial fall , as a result of direct blow over the
greater trochanter.
The # may result either from a Rotation violence at the
hip due to tripping on the floor & falling.
Major trauma in young adults like RTA , fall etc.

12. Classification
Femoral neck fractures are two broad groups as 1) intracapsular
fractures & 2) Extracapsular fractures
1) Intracapsular fractures r divided according to level of # line in
the neck includes:
a) Subcapital: femoral head/neck junction
b) Transcervical: midportion of femoral neck
c) Basalcervical: base of femoral neck
2) Extra capsular neck of femur fractures (#NOF) are fractures of
the neck of the femur which occur outside the capsule of the hip
joint. As such the risks of avascular necrosis of the femoral head.

14. Gardens classification (1961)
Grade 1: incomplete fracture of the femoral neck.
Grade 2: complete fracture without displacement.
Grade 3: complete fracture with partial displacement.
Grade 4: complete fracture with total displacement.

16. Pauwels (1935) Classification
Pauwel's angle is the angle between the line of a fracture of the
neck of the femur and the horizontal as seen on an anterio-
posterior radiograph
Pauwel's angle is named after the German orthopedist Friedrich
Pauwels.
Classification:-
• Type I: Pauwels’ angle less than 30 degrees
• Type II: Pauwels’ angle between 30 and 70 degrees
• Type III: Pauwels’ angle more than 70 degrees

17. Pauwels Classification
stable Less stable unstable
Images from: Court-Brown, C. et al. Rockwood & Greens Fractures in Adults. Philadelphia: Lippincott Williams & Wilkins, 2014

18. Clinical features
 Pain
Restriction of movements of the affected hip
On examination : -
• Tenderness over the anterior hip joint line
• Minimal shortening and external rotational deformity of
the affected limb due to the fracture being intracasular
• Active straight leg raising is difficult
• In impacted # complains : - Groin pain , restriction of hip
movement

19. Investigations
1. X – ray AP and lateral view of the hip joint.
Following points are noted : -
The extent of fracture line whether complete or incomplete
The fracture angle
Break in the shenton`s line
Prominent lesser trochanter
the degree of osteoporosis (Singh`s index)
Shenton's line is an imaginary line drawn along the inferior
border of the superior pubic ramus (superior border of the
obturator foramen) and along the inferomedial border of the
neck of femur. This line should be continuous and smooth.
Interruption of Shenton's line can indicate
fractured neck of femur
- named after the English radiologist Edward Warren Hine
Shenton (1872-1955)

20. Singh`s index
- it measures the degree of
osteoporosis in the
proximal femur based on
radiographic evaluation of
the trabecular pattern and
helps to decide the choice
of implants.

21. 2. MRI
MRI is both sensitive and specific in the detection of femoral neck
fractures, because it can show both the actual fracture line and the
resulting bone marrow edema.
The fracture line can be visualized as linear low-signalintensity areas
surrounded by bone marrow edema, which is hypointense relative to
normal marrow on T1-weighted images or hyperintense on T2-
weighted images.
3. COMPUTED TOMOGRAPHY
CT plays an important role in evaluating the hip after a fracture.
3. Nuclear medicine
Nuclear medicine studies with technetium-99m methylene
diphosphonate (99mTc-MDP) have also been found to be effective in
predicting healing complications related to femoral neck fractures.

22. MANAGEMENT:-
1. Emergency condition and should be reduced and fixed within 24 hours to
get an optimum result.
2. Early anatomical reduction which helps prevent further vascular damage
Impaction of the # fragments.
3. Symptomatic treatment ( bed rest , NSAIDs & Others)
4. Osteotomy in early stages
5. Hemireplacement prosthesis ( acetabular cartilage viable)
7. Total hip replacement (acetabular cartilage is not viable )
8. Arthrodesis (joint fusion )
9. Hip spica plaster in children
10. ORIF

23. Broad treatment guidelines
AGE GROUP UNDISPLACED
More than 70 years DHS
Young adults DHS
Children HIP spica
DHS = dynamic hip screws
THR = total hip replacement
DISPLACED
• Prosthesis
• THR
• DHS
• Osteotomy or
prosthesis
• Multiple Moore`s
pinning
• Osteotomy
• arthrodesis
Multiple Moore`s pinning

24. Garden 1 : -
Conservative : - Hip spica ( old # , unfit for surgery )
Surgery : - multiple Moore`s pinning
Grade 2 : - (# complete )
DHS or multiple cannulated AO screws
Grade 3 / 4 : -
Conservative : - Hip spica , leg traction
Surgery : -
Anatomical reduction , impaction and stable internal fixation
Treatment plans as per Garden`s classification : -

25. Reduction techniques
Closed reduction with hip in extension : -
Whitmann`s method : -
Extension + internal rotation +abduction movements of the hip
Mc Elevenny : -
Extension + external rotation + internal rotation +adduction movement.
Closed reduction with hip in flexion
Smith peterson : -
Slight hip flexion +then internal rotation +abduction + extension
Lead better method : -
Flexion of hip , traction along long axis of femur , thigh internally
rotated and abducted.

26. Other treatment options
After 70 years ,in Displaced # of femoral neck ,
treatment options : -
 Hemireplacement
 Osteotomy
 THR

27. Hip spica plaster

28. Arthrodesis (joint fusion )

29. Dynamic hip screw- DHS
Most commonly used device for
both stable and unstable fracture
patterns.
Plate angle is variable 130 to 150
degrees.
Has to be positioned centrally in
the femoral head.
Use of radiological views to
know the exact position.

30. Austin Moore's prosthesis. / Total Hip Replacement

31. Closed Reduction
• Flexion, slight
adduction, slight
traction
• Apply traction,
internally rotate to 45
degrees, followed by
full extension, slight
abduction

32. Complications
– Avascular Necrosis Occurred In 40%.
– Coxa Vara In 36%
– Non-union In 36%
– Premature Physeal Closure In 38%,
– Shortening In 55%
– , Arthritic Changes In 34%
– Coxa Valga In 9%,
– Coxa Magna In 2%
– Post-operative Infection In 23% Of Patients.

34. Femoral neck fracture Physiotherapy
Management after Surgery
During the 1st week:
1. Inspected the wound for prevent infection. --Adequate Antibiotic / Dressing
2. Pulmonary embolism and hypovolaemia--- Anticoagulant Medications as Warfarin
& Heparin and for hypovolmia IV fluid, Oxygen as required, Fresh frozen plasma or
blood transfusion
3. Prevent bedsores change the position every 2 hrs.
4. Patients treated with hemiarthroplasty should avoid keeping the hip in adduction or
internal rotation to prevent redislocation.
5 Movements:
A full ROM of the ankle (ATM),
Gentle active movements of flexion and extension of the hip and knee onset of pain
Caution: No passive range of motion at this stage.
6. Exercises:
 Iometric gluteal and quadriceps exercises are begun.
Strengthen of calf muscle to prevent thrombophlebitis and deep vein thrombosis.
7. Weight-bearing: End of first week, weight bearing with the help of a crutch or walker
using a 3-point gait may be permitted.

35. 8. Activities of daily living: Use of raised toilet seat and chair, wearing the
trousers from the affected limb first and removing it from the unaffected limb,
rolling on to the unaffected side before getting up from the bed.
During 2-4 weeks:
a. Movements: Active and active-assistive movements of the hip, knee and ankle
can be started. (Note- No passive movements).
b. Exercises: Ankle isotonic exercises are continued.
Isometric exercises for the hip and knee.
c. Weight-bearing: This has to be done on the following :
1. First the patient is advised prone lying.
2. Next as a preclude to weight bearing, four point kneeling is advised.
3. Then patient is advised to bear weight on the knees.
4. Next, knee walking is encouraged.
cont..................

36. 5. Patient may now be allowed to bear the weight on the affected extremity
either partially or fully with using crutches or walker .
d. Activities of daily living: Modifications in activities of daily living are the
same as mentioned earlier.
During 4-8 weeks:
1. Continued above Tx protocol.
2. In supine patient can now flex the hip upto 90 degree, by the self-assisted "heel
drag", (i.e. dragging the heel upto the buttocks with the help of the normal leg).
3. Self assisted exercises in sitting with the legs hanging over the edge of the bed and
supporting and lifting the affected limb with the unaffected leg.
4. Self-resistive exercises for the hip and knee muscles can be carried out with
Theraband.

37. After 8 weeks:
1. CPM (continuous passive motion) apparatus is begun to the hip and knee.
2. Isotonic and isokinetic exercises to the hip and knee are initiated alongwith
progressive resistive exercises.
3. Weight-bearing with the affected extremity with the help of crutches or walker.
4. Activities of daily living can be allowed normally with the help of assistive
devices.
By 12-16 weeks:
1. Full weight-bearing is allowed.
2. Full active and passive range of motion exercises are permitted to the hip and
knee joints.
3. Isometrics, isotonic and progressive resistive exercises are continued to the hip,
knee and ankle joints.
4. Patient can now carry out all the activities of daily living independently.

38. THANKS