Journal of Orthopaedic Surgery 2011;19(1):13-7

Neglected femoral neck fractures in adults

Gurvinder Singh Kainth, Yuvarajan P, Lalit Maini, Vinod Kumar

Department of Orthopaedics, Maulana Azad Medical College and associated Lok Nayak Hospital, Delhi, India

ABSTRACT
Purpose. To assess treatment outcomes in adults
with neglected femoral neck fractures, and propose
a treatment protocol based on bone quality measured
by the Singh index.
Methods. 16 men and 6 women aged 18 to 48 (mean,
33) years presented with neglected (>3 weeks old)
femoral neck fractures. Those with good bone quality
(Singh index, >3) underwent closed reduction and
valgus osteotomy and fixation with 120 double angle
blade plates (group 1, n=8), whereas those with poor
bone quality (Singh index, <3) and/or communition
of the posterior femoral neck underwent fibular
grafting and internal fixation with one or two 7-mm
cannulated cancellous screws (group 2, n=14).
Functional outcome was assessed at the 6-month
follow-up, according to modified Askin and Bryan
criteria.
Results. The mean delay in surgery was 12 (range,

421) weeks. Patients were followed up for a mean

of 19 (range, 1224) months. The mean time to union
was 20 (range, 1252) weeks. The mean time to full
weight bearing was 18 (range, 1240) weeks. All
patients achieved bone union except one in group 1
who had non-union and breakage of the blade plate
at week 20 and underwent total hip arthroplasty.
Other complications included slippage of fibular graft
(n=1), delayed union (n=1), avascular necrosis of the
femoral head (n=2, Fig. 6), limb length discrepancy
(n=3), and superficial infection (n=1). Functional
outcome was excellent in 2 patients, good in 17, and
poor in 3.
Conclusion. Valgus osteotomy and double angle
blade plate fixation, and fibular grafting and
cancellous screw fixation appeared to be appropriate
treatments for neglected femoral neck fractures in
adults.
Key words: bone plates; bone screws; bone
transplantation; femoral neck fractures; fibula; osteotomy

Address correspondence and reprint requests to: Dr Lalit Maini, 22 Samachar Apartment, Mayur Vihar Phase I, Delhi, 110091,
India. E-mail: lalit_maini@rediffmail.com

GS Kainth et al.

Journal of Orthopaedic Surgery

INTRODUCTION

grafting and internal fixation with one or two 7-mm

cannulated cancellous screws (group 2, n=14).
Resorption and communition of the posterior
femoral necks of both hips were assessed using
anteroposterior and lateral radiographs. Magnetic
resonance imaging was not performed for detection
of avascular necrosis of the femoral head, which was
not contraindicated for either procedure.
Patients were operated on via the lateral approach
under regional anaesthesia and under C-arm image
intensifier control; the fracture site was not exposed.
In group 1, a wedge of bone was removed and used as
a graft, and the angle of fracture was made close to 30
horizontally to bring the fracture under compression
(Fig. 3). In group 2, a fibular graft was taken from the
opposite side. A slot for the graft was created with
a dynamic hip screw reamer after a guide wire for
the screw was placed. The graft was placed below the
cannulated cancellous screw (Fig. 4).
Postoperatively, group 1 patients were allowed to
mobilise on the unaffected side with a walker as soon
as pain decreased and they felt confident to stand
with support. Group 2 patients were kept nonweight
bearing and immobilised in a Thomas splint for at
least 6 weeks, as they had poor bone quality. In both
groups, partial weight bearing was allowed on the
affected side after 6 weeks, and full weight bearing
was allowed only after bone union was achieved.
Patients were followed up at weeks 2 and 6 and
month 3, and then 2 monthly until month 6. Bone
union was assessed, as were clinical (range of motion,
degree of associated pain, and ability to bear weight
with or without assistance) and radiological (presence
of bridging trabeculae and implant migration)
outcomes. Functional outcome was assessed at the
6-month follow-up, according to modified Askin and
Bryan4 criteria.

14

Total hip arthroplasty is a standard treatment for

older adults with femoral neck fractures.15 The
treatment protocol for younger adults (<60 years
old) with neglected femoral neck fractures remains
controversial. Neglected fractures often lead to
osteopenia, resorption and avascular necrosis of
the femoral neck, difficulty in reduction, and severe
communition. These problems prolong future
surgery and increase the risks of implant failure and
non-union. We aimed to assess treatment outcomes
in adults with neglected femoral neck fractures, and
propose a treatment protocol based on bone quality
measured by the Singh index.6
MATERIALS AND METHODS
From April 2004 to December 2005, 16 men and
6 women aged 18 to 48 (mean, 33) years presented
with neglected (>3 weeks) femoral neck fractures
(Fig. 1). Those with good bone quality (Singh
index, >3) underwent closed reduction and valgus
osteotomy and fixation with 120 double angle blade
plates (group 1, n=8), whereas those with poor bone
quality (Singh index, <3) and/or communition of
the posterior femoral neck (Fig. 2) underwent fibular

Neglected (>3 weeks old) femoral neck

fractures in adults

History of arthritic joint?

Yes

No
Resorption of femoral
neck (>2.5 cm)

Fibular grafting
and cancellous
screw fixation

Arthroplasty
Replacement

Singh index
<3

Yes

Excision

>3
Communition of
the posterior femoral neck
Yes

No

Valgus osteotomy and

double angle blade
plate fixation

Figure 1 Treatment protocol for femoral neck fractures in

adults.

RESULTS
The mean delay in surgery was 12 (range, 421)
weeks. No patient had signs of avascular necrosis
of the femoral head on radiographs. Patients were
followed up for a mean of 19 (range, 1224) months.
The mean time to union was 20 (range, 1252) weeks.
The mean time to full weight bearing was 18 (range,
1240) weeks. All patients achieved bone union except
one in group 1 who had non-union and breakage of
the blade plate (Fig. 5) at week 20 and underwent
total hip arthroplasty. Other complications included
slippage of fibular graft (n=1), delayed union (n=1),
avascular necrosis of the femoral head (n=2, Fig.
6), limb length discrepancy (n=3), and superficial

Vol. 19 No. 1, April 2011

Neglected femoral neck fractures in adults

15

Figure 4 Fibular grafting and fixation with 2 cancellous

screws.

Figure 2 Severe communition of the femoral neck.

Figure 5 A broken blade plate and persistent non-union.

Figure 3 Valgus osteotomy and fixation with a double

angle blade plate.

infection (n=1) [Table]. Based on modified Askin and

Bryan4 criteria, the functional outcome was excellent
in 2 patients, good in 17, and poor in 3.
DISCUSSION
Healing of the femoral neck and head is the best

outcome after any treatment for femoral neck

fractures.7 Salvaging the femoral head for younger
adults (<60 years of age) with neglected femoral neck
fractures is challenging.8 Total hip arthroplasty is
recommended for those older than 60 years, although
the appropriate treatment should depend not only
on patient age, but also medical status, viability of
the femoral head, size of the remnant femoral neck,
extent of osteoporosis, duration of the disease, and
the state of the joint space.9
Osteosynthesis such as valgus osteotomy,1013

16

Journal of Orthopaedic Surgery

GS Kainth et al.

fibular grafting with internal fixation,14 vascularised

bone grafting,1517 muscle pedicle bone grafting,18
McMurray displacement osteotomy19 have been
advocated for neglected femoral neck fractures.
Nonetheless, there is no guideline for choosing one
over another for a particular fracture.20 Unlike muscle
pedicle grafting, valgus osteotomy and fibular
grafting with internal fixation can be performed
even in patients with resorption and pre-collapse

avascular necrosis of the femoral neck. These

procedures can achieve a painless stable hip, unlike
excision arthroplasty that results in an unstable hip.
Vascularised bone grafting is technically demanding
and not feasible in some patients.
Two of our previous patients who were operated
on for neglected femoral neck fractures had blade
plate cutting out through bone during surgery and
3 weeks after surgery. They had severely osteopenic
bone (Singh index, <3). Thereafter, for such patients
we performed fibular grafting and internal fixation
with cannulated cancellous screws.
Two of our patients developed avascular necrosis
of the femoral head, which might have existed
preoperatively rather than being a postoperative
complication, because following injury it takes one
to 6 months before avascular necrosis of the femoral
head becomes detectable,21 and in our patients the
mean delay in surgery was 12 weeks. Magnetic
resonance imaging could have performed to detect
avascular necrosis of the femoral head, but would not
have changed the treatment modalities, as avascular
necrosis of the femoral head was not contraindicated
for either procedures we were undertaking.22
Osteoporosis is a contributing factor leading
to implant failure. Bone densitometry should be
performed to avoid internal fixation for osteoporotic
patients.23
We formulated a treatment protocol based on
the degree of osteopenia assessed by the Singh
index6 (on radiographs). Although not very accurate
(90% sensitivity but 35% specificity)24 compared to
dual energy X-ray absorptiometry or quantitative
computed tomography, the Singh index is more
affordable and accessible. Communition of the
posterior femoral neck is associated with an

Table
Complications
Complications

Non-union
Implant breakage
Fibular graft slippage
Delayed union
Avascular necrosis of
the femoral head
Limb length
discrepancy
Figure 6 Avascular necrosis of the femoral head.

Superficial infection

No. of patients
Group 1

Group 2

1
1
1
1

0
0
1
0
1

2
(1 lengthening,
1 shortening)
0

1
(shortening)
1

Vol. 19 No. 1, April 2011

increased complication rate.25 Valgus osteotomy was

not performed for such patients, as it is technically
demanding and may result in intraoperative anterior
angulation and difficulty in reduction. Fibular
grafting supports the healing process, but alters

Neglected femoral neck fractures in adults

17

biomechanics (shearing force) at the fracture site.

Healing of femoral neck fractures was influenced
far more by biomechanical than biological factors.10
Valgus osteotomy improves biomechanics, whereas
fibular grafting does not.

REFERENCES
1. DArcy J, Devas M. Treatment of fractures of the femoral neck by replacement with the Thompson prosthesis. J Bone Joint
Surg Br 1976;58:27986.
2. Coates RL, Armour P. Treatment of subcapital femoral fractures by primary total hip replacement. Injury 1979;11:1325.
3. Cartlidge IJ. Primary total hip replacement for displaced subcapital femoral fractures. Injury 1981;13:24953.
4. Broos PL. Hip fractures in elderly people. The surgical treatment in Leuven, Belgium. Acta Chir Belg 1994;94:1305.
5. Gregory RJ, Wood DJ, Stevens J. Treatment of displaced subcapital femoral fractures with total hip replacement. Injury
1992;23:16870.
6. Singh M, Nagrath AR, Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J
Bone Joint Surg Am 1970;52:45767.
7. Holmberg S, Kalen R, Thorngren KG. Treatment and outcome of femoral neck fractures. An analysis of 2418 patients
admitted from their own homes. Clin Orthop Relat Res 1987;218:4252.
8. Roshan A, Ram S. The neglected femoral neck fracture in young adults: review of a challenging problem. Clin Med Res
2008;6:339.
9. Khan AQ, Khan MS, Sherwani MK, Agarwal R. Role of valgus osteotomy and fixation with dynamic hip screw and 120
degrees double angle barrel plate in the management of neglected and ununited femoral neck fracture in young patients. J
Orthop Traumatol 2009;10:718.
10. Pauwels F. Der Schenkelhalsbruch ein mechanisches Problem: Grundlagen des Heilungsvorganges, Prognose and kausale
Therapie. Stuttgart: Ferdinand Enke Verlag; 1935.
11. Jorring K, Movin R. Experience with 79 subtrochanteric valgus osteotomies of the hip. Acta Orthop Scand 1973;44:46772.
12. Marti RK, Schuller HM, Raaymakers EL. Intertrochantric osteotomy for non-union of the femoral neck. J Bone Joint Surg Br
1989;71:7827.
13. Ballmer FT, Ballmer PM, Baumgaertel F, Ganz R, Mast JW. Pauwels osteotomy for nonunions of femoral neck. Orthop Clin
North Am 1990;21:75967.
14. Nagi ON, Gautam VK, Marya SK. Treatment of femoral neck fractures with a cancellous screw and fibular graft. J Bone Joint
Surg Br 1986;68:38791.
15. LeCroy CM, Rizzo M, Gunneson EE, Urbaniak JR. Free vascularized fibular bone grafting in the management of femoral
neck nonunion in patients younger than fifty years. J Orthop Trauma 2002;16:46472.
16. Chang MC, Lo WH, Chen TH. Vascularized iliac bone graft for displaced femoral neck fractures in young adults. Orthopedics
1999;22:4939.
17. Hou SM, Hang YS, Liu TK. Ununited femoral neck fractures by open reduction and vascularized iliac bone graft. Clin
Orthop Relat Res 1993;294:17680.
18. Meyers MH, Harvey JP Jr, Moore TM. Treatment of displaced subcapital and transcervical fractures of the femoral neck by
muscle-pedicle-bone graft and internal fixation. A preliminary report on one hundred and fifty cases. J Bone Joint Surg Am
1973;55:25774.
19. McMurray TP. Ununited fractures of the neck of the femur. J Bone Joint Surg Am 1936;18:31927.
20. Sandhu HS, Sandhu PS, Kapoor A. Neglected fractured neck of the femur: a predictive classification and treatment by
osteosynthesis. Clin Orthop Relat Res 2005;431:1420.
21. Lafforgue P. Pathophysiology and natural history of avascular necrosis of bone. Joint Bone Spine 2006;73:5007.
22. Sen RK. Management of avascular necrosis of femoral head at pre-collapse stage. Indian J Orthop 2009;43:616.
23. Swiontkowski MF. Intracapsular fractures of the hip. J Bone Joint Surg Am 1994;76:12938.
24. Masud T, Jawed S, Doyle DV, Spector TD. A population study of the screening potential of assessment of trabecular pattern
of the femoral neck (Singh index): the Chingford Study. Br J Radiol 1995;68:38993.
25. Keller CS, Laros GS. Indications for open reduction of femoral neck fractures. Clin Orthop Relat Res 1980;152:1317.