Femoral Neck Fracture: Types, Surgery, and Recovery

A femoral neck fracture is a break across the narrow bridge of bone connecting the ball of the hip joint to the shaft of the thighbone, and it ranks among the most consequential injuries in medicine. In older adults it almost always requires surgery, carries a one-year mortality rate that can exceed a quarter of all patients, and triggers a cascade of decisions about implant choice, surgical timing, blood-supply preservation, and long-term bone health that can shape a person’s mobility for the rest of their life. The fracture sits in a region with an unusual and precarious blood supply, which is why even perfectly repaired bone can later die from the inside out. Understanding the injury means understanding that chain of vulnerabilities.

Why the Femoral Neck Is So Vulnerable

The femoral neck is essentially a bottleneck. It is thinner than the shaft below it and the ball above it, and in people with osteoporosis the internal scaffolding of bone in this area thins dramatically, leaving a structure that can snap under forces as mild as a stumble from standing height. But what makes the femoral neck genuinely treacherous is its blood supply. The femoral head, the ball at the top, gets almost all its blood through a handful of small arteries called retinacular vessels that run along the outside of the neck. When the neck breaks, these vessels can tear, kink, or compress. In a study using digital subtraction angiography to visualize those vessels directly, the majority of fracture patients showed injury to at least one retinacular vessel, and many had two or even all three damaged.¹ The degree of vessel damage is directly linked to how much the fracture pieces have shifted apart, and that displacement is the single most important factor in deciding what surgery a patient needs.

How Doctors Classify These Fractures

The most widely used system for grading femoral neck fractures is the Garden classification, which sorts them into four types based on how displaced the fracture fragments are on an X-ray. The practical division comes down to two camps: undisplaced fractures (Garden types I and II), where the bone ends are still roughly aligned, and displaced fractures (Garden types III and IV), where the pieces have shifted significantly. That distinction drives the surgical decision between trying to fix the bone in place versus replacing part or all of the hip joint.² A large retrospective study confirmed that Garden classification, along with factors like age, time to surgery, presence of osteoporosis, and the degree of three-dimensional displacement, all independently predict whether the femoral head will later lose its blood supply and collapse.³

When Fractures Do Not Show Up on X-Ray

Roughly one in twenty suspected hip fractures will look normal on an initial X-ray despite the patient having severe pain and an inability to bear weight. These are called occult fractures, and missing them means a patient may walk on a bone that is about to fully break through. MRI is the gold standard for catching these hidden fractures, consistently outperforming CT in sensitivity, specificity, and overall accuracy.⁴ CT is a reasonable fallback when MRI is not available or the patient cannot tolerate it, with a pooled sensitivity of about 94%, but that still means it misses around one in sixteen fractures that MRI would catch.⁵ The practical takeaway: if you have hip pain after a fall and the X-ray is clear, an MRI should follow if there is still concern. A negative CT does not completely rule out a fracture.⁶

Internal Fixation for Fractures That Stay in Place

When the fracture is undisplaced or only minimally shifted, surgeons generally try to preserve the patient’s own femoral head by fixing the bone with metal hardware. The two main options are cannulated cancellous screws, which are individual screws placed across the fracture, and a sliding hip screw (also called a dynamic hip screw), which is a single large screw attached to a side plate on the thighbone. A systematic review comparing these two approaches found no significant difference in long-term hip function as measured by the Harris Hip Score, but the sliding hip screw group had fewer complications and faster fracture healing times.⁷ For fractures with a more vertical orientation, the advantage of the sliding hip screw becomes more pronounced: a meta-analysis found that the nonunion rate was significantly higher with cannulated screws than with a dynamic hip screw for these steeper fracture patterns.⁸

Despite those findings, cannulated screws remain widely used because they are quicker to insert and require a smaller incision. The choice often comes down to the fracture geometry and the surgeon’s judgment about how stable the fixation needs to be.

Joint Replacement for Displaced Fractures

In older adults with displaced femoral neck fractures, the blood supply to the femoral head is usually too compromised to trust that the bone will heal on its own, even with screws. The standard approach is to replace the damaged joint. The two main options are hemiarthroplasty, which replaces only the femoral head (the ball), and total hip arthroplasty, which replaces both the ball and the socket.

A landmark trial published in the New England Journal of Medicine randomized over 1,400 patients with displaced femoral neck fractures to one procedure or the other. The rate of the primary composite outcome (death or serious complications within two years) was essentially identical between groups: about 8% in each. Function scores modestly favored total hip arthroplasty. However, dislocation, where the new joint pops out, was roughly twice as common after total hip arthroplasty compared to hemiarthroplasty. Mortality was similar.⁹

The picture shifts over longer time horizons. In active patients over 75 followed for five or more years, total hip arthroplasty delivered meaningfully better hip function scores (about 81 versus 73 on the Harris Hip Score) and better quality of life. Over a quarter of hemiarthroplasty patients developed erosion of the hip socket from the metal ball grinding against natural cartilage, compared to none in the total hip group.¹⁰ A meta-analysis of randomized trials in the same age group confirmed these trends: total hip arthroplasty was superior for pain, function, and quality of life, but came with a longer operation time and a higher dislocation rate.¹¹

In short, for patients who are relatively active and expected to live many more years, total hip arthroplasty tends to pay off over time. For frail patients with shorter life expectancy, the simpler, faster hemiarthroplasty may be the safer bet.

Unipolar Versus Bipolar Hemiarthroplasty

When hemiarthroplasty is chosen, the implant comes in two designs. A unipolar prosthesis has a single fixed head. A bipolar prosthesis has an inner bearing that allows motion within the implant itself, theoretically reducing wear on the patient’s natural socket. A pooled analysis of over 30,000 patients found that bipolar implants outperformed unipolar ones in hip function, range of motion, and reoperation rates, with unipolar implants showing higher rates of socket erosion over time.¹² A randomized trial focusing on the oldest patients echoed the socket-erosion finding: 20% of unipolar hemiarthroplasty patients had visible erosion at one year compared to 5% of bipolar patients.¹³ That said, a large prospective cohort found no difference in reoperation or dislocation rates between the two designs, suggesting the clinical gap may be smaller than the radiographic one.¹⁴

Cemented Versus Uncemented Stems

Another critical decision is whether to fix the prosthesis stem into the thighbone with bone cement or to rely on a press-fit design that the bone grows into. Cemented fixation consistently reduces implant-related problems, especially periprosthetic fractures, and registry data show lower reoperation rates with cemented stems.¹⁵ A large Japanese database study confirmed that cement use significantly reduced the risk of infection and periprosthetic fracture, but came with a higher rate of blood transfusion and a small increase in cerebrovascular events.¹⁶

The main concern with cement is bone cement implantation syndrome, a sudden drop in blood pressure and oxygen during or right after cementing. A multicenter analysis of over 31,000 matched patients found no overall difference in 30-day mortality, but mortality in the first one to ten days after surgery was significantly higher in the cemented group, with the association weakening as the postoperative period lengthened.¹⁷ For the frailest patients, that very early risk is worth discussing.

Why Getting to Surgery Quickly Matters

Every hour a patient with a hip fracture lies waiting for surgery is an hour of pain, immobility, and physiological stress. A large study matching over 27,000 patients found a clear inflection point around the 24-hour mark. Patients who had surgery beyond 24 hours had higher 30-day mortality (about 6.5% versus 5.8%), more pulmonary embolisms, more heart attacks, and more pneumonia compared to those who went to the operating room within a day.¹⁸ These differences persisted at 90 days and a year. One smaller study failed to find a statistically significant link between surgical delay and death, but did find that delays increased the length of hospital stay.¹⁹ The weight of the evidence strongly favors operating within 24 hours whenever medically feasible.

Spinal or General Anesthesia

For decades, many surgeons and anesthesiologists assumed that spinal anesthesia was gentler on elderly hip fracture patients than general anesthesia. A major randomized trial in the New England Journal of Medicine put that assumption to the test and found no difference. The rate of death or inability to walk independently at 60 days was virtually identical between the two groups, and delirium occurred at the same rate regardless of anesthesia type.²⁰ A follow-up analysis of the same trial at one year showed no divergence in survival or recovery of walking ability between spinal and general anesthesia.²¹ The choice can safely be made based on patient anatomy, preferences, and the anesthesiologist’s assessment rather than a blanket assumption that one type is safer.

Complications After Internal Fixation

When the natural femoral head is preserved with screws, the two feared complications are avascular necrosis (where the bone of the femoral head dies due to lost blood supply) and nonunion (where the fracture simply never heals). A systematic review and meta-analysis found that the pooled rate of avascular necrosis was about 21% in patients with displaced fractures compared to about 5% in those with undisplaced fractures.²² A separate meta-analysis of risk factors confirmed that having a displaced fracture (Garden III-IV) raised the odds of avascular necrosis substantially, while gender, age, and time to surgery did not reach statistical significance as predictors.²³

Fixation failure overall, including both avascular necrosis and nonunion, occurred in about 24% of internally fixed patients in one single-center analysis. That study found that operating within one day of injury and using cannulated screws were both associated with lower odds of nonunion.²⁴ A broader meta-analysis of fixation failure risk factors identified female sex, smoking, age over 50, poor fracture reduction, and the use of screws or pins instead of fixed-angle devices as significant predictors of failure.²⁵ Renal impairment has also emerged as an independent risk factor for nonunion.²⁶

One promising screening tool is a specialized bone scan (SPECT/CT) done soon after surgery. In a study of patients who underwent internal fixation, those whose immediate postoperative scan showed normal blood flow to the femoral head had a 100% negative predictive value for avascular necrosis, meaning none of them developed it. Among those who showed reduced blood flow, about a quarter went on to develop avascular necrosis.²⁷

Postoperative Delirium

Delirium, a sudden state of confusion and disorientation, hits roughly one in five older adults after hip fracture surgery regardless of anesthesia type. It is not a minor nuisance: patients who develop delirium have longer hospital stays, worse functional outcomes, and higher mortality. A systematic review identified the strongest risk factors as preexisting cognitive impairment (which roughly triples the odds), advanced age, living in an institution, heart failure, multiple chronic conditions, and morphine use.²⁸ In the very oldest patients (those in their nineties), having four or more medical conditions, longer waits before surgery, and receiving general rather than regional anesthesia were independent risk factors for delirium.²⁹

The most effective strategy for preventing delirium combines early identification of high-risk patients, avoidance of medications known to trigger confusion, and comprehensive orthogeriatric care where geriatricians and orthopedic surgeons manage patients together from admission.³⁰

Orthogeriatric Co-Management

The idea of embedding a geriatrician in the orthopedic team has been one of the clearest success stories in hip fracture care. A systematic review and meta-analysis found that orthogeriatric models reduced in-hospital mortality by about 28%, one-year mortality by 14%, and the incidence of delirium by about 19%, while also shortening hospital stays by roughly a day and a half.³¹ A prospective study comparing orthogeriatric co-management to standard care confirmed improvements across a range of outcomes, including earlier surgery, fewer cardiac complications, fewer blood clots, better mobility at 30 days, and better quality-of-life scores at four months.³² Shared-care models, where geriatricians and surgeons jointly direct care from the ward rather than consulting from a distance, appear to produce the largest reductions in hospital stay.³³

Recovery and Rehabilitation

Getting up and bearing weight soon after surgery has become standard practice. One study of geriatric hip fracture patients found that mobilizing within 24 hours of surgery did not increase pain or harm hip mobility, effectively showing it was safe even if it did not translate into a shorter hospital stay.³⁴ A randomized controlled trial went a step further, testing a standardized early weight-bearing training program. Patients in the program had significantly better hip function scores both before discharge and at one month, less pain at rest, longer daily weight-bearing duration, and better independence in daily tasks.³⁵ The message is clear: structured early mobilization does more than just prevent blood clots and pneumonia. It translates into tangible functional gains.

Long-Term Mortality

Hip fractures carry a mortality burden that extends well beyond the hospital. In a population-based study of patients aged 65 and older, roughly 27% died within the first year, and nearly 80% had died by the end of the follow-up period. Men fared worse than women, with an age-adjusted risk of death about 55% higher. The most common causes of death were cardiovascular disease, followed by dementia and Alzheimer’s disease, not surgical complications.³⁶ This underscores that a hip fracture in an elderly person is not an isolated event. It is often a marker of overall frailty, and the causes of death afterward reflect the broad vulnerability of the patient rather than the fracture alone.

Preventing the Next Fracture

Perhaps the most frustrating gap in hip fracture care is what happens after the patient leaves the hospital. Most people who break a hip have underlying osteoporosis, yet shockingly few receive medications to strengthen their bones afterward. A cross-national study found that within three months of a hip fracture, only about 11% of U.S. Medicare patients filled a prescription for an osteoporosis medication. Rates were somewhat better elsewhere but still low: roughly 24% in Spain and 39% in Korea.³⁷ These drugs work. A systematic review and meta-analysis confirmed that anti-osteoporosis medications significantly reduced the risk of secondary fractures, with bisphosphonates and parathyroid hormone analogs particularly effective for preventing non-vertebral fractures.³⁸

Fall prevention is the other half of the equation, and the evidence here is mixed. A randomized study of a fall-prevention program in patients who had undergone femoral neck fracture surgery found that falls and injuries were reduced while patients were still in the hospital, but the benefits did not persist after discharge.³⁹ A systematic review of exercise-based rehabilitation after hip surgery noted that while fall-prevention advice and home modifications were frequently mentioned, the rate of secondary falls was rarely measured in studies, and no clear rehabilitation protocol for preventing repeat falls has been established.⁴⁰ Fall prevention, in other words, needs to be woven into everyday life on an ongoing basis rather than treated as a one-time hospital intervention.

When Children Break Their Femoral Neck

Femoral neck fractures in children are rare, usually resulting from high-energy trauma like car crashes or significant falls, and they behave very differently from adult fractures. The complication rate is high because the blood supply to the growing femoral head is even more vulnerable than in adults. Avascular necrosis, abnormal neck angulation (coxa vara), premature closure of the growth plate, and nonunion are all common and often lead to poor outcomes.⁴¹

Treatment in children typically involves internal fixation with screws, but the presence of a growth plate near the top of the femur complicates things. Screws that cross the growth plate can cause premature closure, which may lead to a shorter leg or angular deformity. Yet the alternative, stopping screws short of the growth plate, risks inadequate fixation and nonunion. A systematic review noted that premature growth-plate closure is the most common complication of pediatric femoral neck fracture fixation, with rates reported anywhere from about 7% to over 60% depending on the study and technique.⁴² In younger children, a hip spica cast (a rigid cast covering the hip and upper leg) is added after fixation for extra stability. A comparison of proximal femoral locking plates versus cannulated screws found no significant difference in union rates or avascular necrosis rates, though locking plates appeared to better maintain the geometry of the upper femur.⁴³ Pediatric femoral neck fractures remain one of the more anxiety-inducing injuries in children’s orthopedics precisely because even well-executed surgery carries substantial complication risks.