Treatment of Nondisplaced Fractures of the Femoral Neck

In all the reported series of impacted femoral neck fractures treated conservatively the incidence of disimpaction is between 8% and 15%. It is impossible at the time the patient presents to predict which fractures will undergo disimpaction. Disimpaction requires a secondary operation to prevent nonunion and subsequent disability. Internal fixation is, therefore, considered the most satisfactory treatment of an impacted fracture in every case. This will add certainty to an already stable situation and allow immediate weight-bearing without concern for stability of the fracture. If elementary precautions are taken during operation, disimpaction will not occur. No attempt should be made to improve the position of a markedly valgus fracture in an attempt to prevent subsequent avascular necrosis since this can result in conversion of the fracture to an unstable one. The internal fixation of impacted fractures may be by use of a Smith-Petersen nail, by Moore pins or preferably by a screw of the Garden type. This has the advantage of not separating the fracture during insertion and secures firm fixation of the fragments. The operation is short and simple, particularly when an image intensifier is employed, and the patient may begin weight-bearing on the day following operation and return home after a few days. There is no higher risk of avascular necrosis after internal fixation than after conservative treatment, provided the nail or screw is placed in the center of the femoral head. Conservative treatment is indicated only for those patients who present with an impacted femoral neck fracture several weeks after their injury and are walking without pain.