Management of femur neck fractures in young adults under the age of 60 years

Femur neck fractures in young adults account for 3–10% of all hip fractures, and management remains a challenge for the orthopaedic surgeon. Reoperation rates remain high after fixation of these fractures due to avascular necrosis, non-union, implant failure and removal of hardware. Complication rates are higher in displaced fractures, and patients who undergo revision to total hip arthroplasty (THA) have poorer outcomes compared with primary THA. Injury factors, fracture pattern, physiological age, timing of surgery, the role of capsulotomy and implant choice all need to be carefully considered in managing these fractures. Preserving the native hip joint is the standard of care in these patients but primary THA is becoming an attractive option due to the improvements in bearing surfaces and longevity of implants. There is no role for conservative management of fractures in this age group. Absolute anatomic reduction and stable fixation remains the goal of hip-preserving surgery. Open reduction is often necessary. Various fixation options are available from the more commonly used cannulated screws and dynamic hip screw to the newer generation hybrid plates with telescoping screws. Cannulated screws (CS) are adequate for stable fracture (Garden 1 and 2) patterns, whereas the dynamic hip screw (DHS) is biomechanically superior for unstable fractures. Neck shortening after using sliding screws is common but does not seem to influence clinical outcomes. Cephalomedullary nails are an acceptable load-bearing alternative. Proximal femur locking plates have high failure rates and should be avoided. New generation hybrid plates have shown promising results with fewer non-union rates than CS and DHS systems. Primary THA can be considered in exceptional cases where there are significant comorbidities, poor bone stock or in a patient that will be unable to tolerate a second surgery if fixation fails. Hemiarthroplasty should be avoided in this age group. The management of these fractures in South African government hospitals should be supervised by experienced surgeons whenever possible. Level of evidence: Level 5