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femoral neck fractures in young patients

Imagine this scenario…a young male patient who is an avid marathon runner who fell while hiking and sustained a fracture of the femoral neck.  He has minimal co-morbid medical conditions, is brought to the hospital within 2 hours of the injury, and he has no other injuries or abnormalities that would preclude him from going to the operating room.  In addition, there is every reason to believe that this patient is likely to have excellent bone mineral density and the purchase of screws in the bone will be extremely solid.  This patient deserves the best possible chance at keeping their native hip.  The patient is young, his healing potential is very good, and he expects to be able to return to activities such as running and arduous hiking that are not advisable for people with prosthetic joints.

For example, here is the pre-operative xray of a patient in his late 40′s who sustained a fracture of the femoral neck. Even though the fracture is somewhat displaced, this patient was immediately taken to the operating room where the fracture was fixed with 3 7.3mm cannulated screws.  IF the blood supply to the femoral head was not torn or kinked by the fracture and the fracture heals, this person will have a basically normal hip until later in life when arthritis is likely to set in.  Without prompt treatment, it is much more likely that this patient will require a half of a hip replacement which is not likely to be a great long term solution for a patient who is so young…

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In this setting, this is a relative orthopedic emergency.  The longer the fracture is left in a displaced position, the more likely it is that the artery that supplies the femoral head is going to clot, tear, or fail to be able to supply the femoral head with an adequate amount of blood after the fracture has been fixed.  This patient should go to the operating room in the middle of the night if necessary.  Everyone agrees that this patient should be fixed emergently, but there is considerable debate about the best procedure.  Dr. Mark Swiontkowski was one of the early champions of the notion that these fractures should be treated as a surgical emergency.  He has also suggested that performing an open reduction and a capsultomy (opening the hip capsule in order to evacuate the blood in the hip joint that is under pressure) may improve the chance that the head will revascularize.  However, in a recent article in the journal Instructional Course Lectures he notes that the role of a capsulotomy in the treatment of femoral neck fractures is still controversial.  The complete abstract of the this lecture, which is a succinct explanation of the current consensus opinion on the management of femoral neck fractures in younger patients is located here.

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