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Clinical Practice Guidelines

Neck of femur - Fracture clinics

  • Fracture Guideline Index

    See also:  Neck of femur (NOF) fractures - Emergency Department

    1. How often should these fractures be followed up in fracture clinics?
    2. What should I review at each appointment?
    3. What are the potential complications associated with this injury?
    4. When should I refer for an orthopaedic consultant opinion?
    5. What are the indications for discharge?

    1. How often should these fractures be followed up in fracture clinics?

    Fracture type

    First appointment

    Subsequent review appointments (in consultant clinic)

    Discharge advice to parents

    All

    1-2 weeks post-injury, x-rays dependent on reduction and stabilisation method

    Transfer to consultant clinic

    Consideration of bone scan at 3-7 days post-injury to assess vascular status of the femoral head

    At 4-6 weeks post-injury for clinical and x-ray review in the consultant clinic

    Consideration of a bone scan according to the treating consultant

    After the first visit, these patients should be followed in the consultant clinic

    Return to sports only on advice from consultant

    2. What should I review at each appointment?

    At 2 weeks, the wound should be checked. Weight bearing status should be reviewed.  If x-rays are taken, fracture reduction should be assessed.

    3. What are the potential complications associated with this injury?

    • Avascular necrosis (AVN, also called osteonecrosis) of the femoral head - this is the most common complication following a NOF fracture.  The risk of disruption of the blood supply to the femoral head is dependent on fracture type and age. The risk for a displaced Delbert type I fracture is up to 100%, for type II fracture is up to 61%, for type III fracture is up to 27% and for type IV fracture is 14%
    • Coxa vara (neck shaft angle <120 degrees) - this is the second most common complication and has been reported to occur in up to 30% of cases. This can occur from progressive deformity in initially undisplaced fractures or from loss of reduction in displaced fractures.  More severe coxa vara can cause abductor dysfunction and result in a Trendelenburg gait pattern
    • Growth arrest - the physis of the femoral head contributes to approximately 15% of overall limb length (3-4 mm of growth per year).  Reports of early physeal closure following NOF fractures vary between an incidence of 5-65%.  It is associated with AVN and transphyseal fixation. Premature physeal closure can result in coxa vara and limb length discrepancy
    • Chondrolysis - this is uncommon but it can be associated with osteonecrosis of the femoral head. This is due to disruption of the blood supply to the cartilage of the femoral head
    • Infection - this is uncommon after surgical fixation of femoral neck fractures.  It is reported to occur in less than 1% of cases

    4. When should I refer for an orthopaedic consultant opinion?

    Any concerns with wound healing, loss of reduction or complications.

    After the first visit, these patients should be followed up in the consultant clinic.

    5. What are the indications for discharge?

    These patients should be followed in the consultant clinics after the initial check.  Discharge from the consultant clinic can be considered after the patient is two years post-injury with no complications present. 

    References (Outpatient setting)

    Boardman MJ, Herman MJ, Buck B, Pizzutillo PD. Hip Fractures in Children. J Am Acad Ortho Surg 2009; 17:162-73.

    McCarthy JM, Noonan K. Fractures and traumatic dislocations of the hip in children. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.769-96.