Anatomy Msk · Year 1 · from Anatomy Msk
Case 1: Femoral Neck Fracture in the Elderly
Clinical Image
Source: Wikimedia Commons - Garden Classification - CC BY-SA 3.0
Case Presentation
An 82-year-old woman with a history of osteoporosis and dementia is brought to the emergency department from her nursing home after being found on the floor beside her bed. Staff heard a loud noise and found her unable to stand. She is confused at baseline and cannot provide a clear history, but points to her right hip when asked about pain. Physical examination reveals the right lower extremity is shortened and externally rotated compared to the left. There is significant tenderness over the right groin and hip. Attempted range of motion of the hip elicits severe pain. She is unable to perform a straight leg raise on the right side. Neurovascular examination reveals intact distal pulses and sensation. Radiographs demonstrate a displaced subcapital femoral neck fracture (Garden type IV). Laboratory studies show mild anemia and normal renal function. Given the displacement and patient's age, she is taken to the operating room the following day for hemiarthroplasty (replacement of the femoral head with preservation of the native acetabulum). She is mobilized on postoperative day one and discharged to rehabilitation on day three.
Key Learning Points
- The femoral neck is intracapsular; fractures disrupt the retinacular vessels that supply the femoral head
- The medial femoral circumflex artery provides the primary blood supply to the femoral head via retinacular branches
- Displaced femoral neck fractures have high rates of avascular necrosis and nonunion in elderly patients
- Classic presentation: shortened, externally rotated leg due to unopposed action of iliopsoas and external rotators
- Garden classification grades fracture displacement: Types I/II (nondisplaced) often treated with fixation; Types III/IV (displaced) treated with arthroplasty in elderly