Subcapital fractures: in the bucket or on top of the neck?

Femoral neck fractures have a 30% reoperation rate when internally fixed. To reduce the reoperation rate, the surgeon must accurately decide which fractures are best fixed and which fractures require a prosthesis. The literature supports the fact that nondisplaced fractures should be internally fixed. Fractures in patients physiologically younger than 65 years should also be fixed if they have no comorbidities. The most important factors in reducing failure rate of fixation are patient selection and anatomic reduction. A femoral neck fracture left in varus is doomed to failure and reoperation. Femoral neck fractures that are displaced in patients older than 65 years require a decision-making algorithm to decide how they should be treated. In the physiologically active patient older than 65 years, internal fixation may be considered. In most patients older than 65 years, prosthetic replacement should be considered. Nursing home patients and patients with comorbidities who are not expected to live longer than 6 to 7 years should receive a hemiarthroplasty. Studies show a high reoperation rate if the patient with hemiarthroplasty survives more than 6 or 7 years. In the active elderly with little or no comorbidities, a total hip replacement should be considered. This is not only cost effective but provides the best pain relief of any of the treatment options for displaced femoral neck fractures. Treatment of femoral neck fractures remains a challenge, but the surgeon must develop an algorithm to select proper treatment options for the patient. The decision-making process is always shared with the patient.