Use full or minimal displacement as a guide when treating subcapital hip fractures

Patient age also dictates the best treatment, with ORIF reserved for those younger than 60 years.

Orthopedic surgeons can help patients with subcapital hip fractures attain optimal outcomes by selecting appropriate treatments based on fracture type, age and bone quality.

After taking those factors into consideration, the treatment choices are straightforward — nonoperative, open reduction internal fixation (ORIF) and a host of arthroplasty options, according to Robert B. Bourne, MD, FRCS(C), London, Ontario.

“For femoral neck fractures, treatment algorithms are helpful,” particularly if they are organized according to minimally displaced and displaced fractures, Bourne said in a presentation he made at the 7th Annual Current Concepts in Joint Replacement Spring 2006 Meeting.

He presented information about which patients are best suited for each treatment and research supporting each alternative.

“For displaced fractures [in patients] over 70, I think the general consensus is that arthroplasty is the way to go. You have choices between a unipolar, bipolar or total hip replacement (THR),” Bourne said.

Most older patients do well with a bipolar or monopolar arthroplasty as a primary procedure, which leaves THR as a salvage option in the event that fails.

But, surgeons need to watch for such THR complications as dislocation, with rates up to 32% in some studies, and loosening, with a reported rate of up to 14%.

Nonoperative treatment has “a very limited role” in managing subcapital hip fractures, he said. The rare times when nonoperative care might be indicated include the following:

When there is a missed fracture;
When the fracture is valgus impacted; or,
When the fracture occurs in someone at high risk for increased morbidity.

ORIF guidelines

When subcapital hip fractures occur in patients younger than 60 years with good bone stock, surgeons can usually perform ORIF. The goal in those situations is attaining a rigid, anatomic reconstruction that facilitates immediate weight-bearing.

“In patients less than 60 years, there seems to be some general consensus that earlier internal fixation is better than late; certainly within the first six to eight hours.”

Bourne cited ORIF techniques that Marc F. Swiontkowski, MD, has found effective in these situations. Among them: centering a sliding hip screw as much as possible or fixing the fracture with three hip screws implanted so they form an inverted “V,” rather than placing them parallel to one another.

Performing a decompressive capsulotomy in conjunction with ORIF is optional, but most surgeons agree that these ORIF cases require continued follow-up to check for avascular necrosis, malunion or nonunion.

About one-third of patients younger than 60 years treated with ORIF eventually require a reoperation. They should be informed of that risk early in the treatment process, Bourne said.

Contraindications for ORIF include suspected severe osteoporosis or known low bone mineral density.

For more information:
Bourne RB. Subcapital fractures: In the bucket or on top of the neck? #85. Presented at the 7th Annual Current Concepts in Joint Replacement Spring 2006 Meeting. May 21-24, 2006. Las Vegas.