Femoral Neck Fractures: Epidemiology, Surgical Anatomy, Classification, & Management

Introduction & Epidemiology

Femoral neck fractures represent a significant public health burden globally, particularly in aging populations. These fractures are predominantly intracapsular injuries of the proximal femur, characterized by their high morbidity and mortality rates. Their incidence is increasing with the global rise in life expectancy and the prevalence of osteoporosis. In regions like Yemen, where demographic shifts and healthcare infrastructure challenges exist, understanding the epidemiology and optimizing management strategies is critical.

Epidemiologically, femoral neck fractures exhibit a bimodal distribution. In younger individuals, they are typically high-energy trauma injuries, often associated with polytrauma. In contrast, in the elderly (>65 years), they are overwhelmingly fragility fractures resulting from low-energy falls, frequently in the context of osteoporosis. Women are disproportionately affected due to postmenopausal osteoporosis. Annual incidence rates vary but generally range from 100 to 250 per 100,000 persons over 65 years. The 1-year mortality rate following a femoral neck fracture in the elderly ranges from 14% to 36%, often attributable to pre-existing comorbidities exacerbated by surgery, immobilization, and subsequent complications such as pneumonia, deep vein thrombosis (DVT), and pulmonary embolism (PE). The economic impact is substantial, encompassing acute care, rehabilitation, and long-term loss of independence.

The management of femoral neck fractures is complex, necessitating careful consideration of patient age, physiological status, fracture displacement, bone quality, and pre-existing comorbidities. Treatment paradigms have evolved from conservative management to diverse surgical interventions, aiming to restore mobility, minimize pain, and reduce mortality. This necessitates a thorough understanding of surgical anatomy, biomechanics, nuanced indications, meticulous surgical technique, and robust post-operative rehabilitation.

Surgical Anatomy & Biomechanics

The surgical anatomy of the proximal femur is crucial for understanding femoral neck fractures and their management. The femoral head receives its primary blood supply from the medial and lateral circumflex femoral arteries, which give rise to ascending retinacular arteries. These vessels ascend within the capsular reflections and are highly vulnerable to injury in intracapsular fractures, particularly with displacement, leading to a high risk of avascular necrosis (AVN) of the femoral head. The foveal artery (artery of the ligamentum teres) contributes a minor, often insufficient, blood supply, particularly in adults.

The femoral neck itself is an area of cancellous bone surrounded by a cortical shell, connecting the femoral head to the intertrochanteric region. Its angulation (angle of inclination, normally 125-135 degrees, and angle of anteversion, normally 10-20 degrees) influences hip biomechanics. Fractures of the femoral neck are classified based on their anatomical location, displacement, and stability.

Key classifications include:
* Pauwels Classification : Based on the angle of the fracture line relative to the horizontal plane, indicating the shear stress across the fracture site.
* Type I: <30 degrees (low shear, more stable)
* Type II: 30-50 degrees (moderate shear)
* Type III: >50 degrees (high shear, most unstable, high risk of nonunion)
* Garden Classification : Based on the degree of displacement and integrity of the medial cortical buttress. This classification is primarily used for guiding treatment decisions, particularly concerning AVN risk.
* Type I: Incomplete, impacted valgus fracture. Stable.
* Type II: Complete, non-displaced fracture. Stable.
* Type III: Complete, partially displaced fracture (often varus displacement, still some trabecular continuity).
* Type IV: Complete, fully displaced fracture (no trabecular continuity, femoral head freely rotated). Unstable, highest risk of AVN.

Biomechanically, the femoral neck is subject to significant compressive and tensile forces during weight-bearing. The trabecular bone within the femoral head and neck is organized into distinct systems (e.g., primary compressive, primary tensile, secondary compressive, secondary tensile) that resist these forces. A fracture disrupts this intricate architecture, compromising load transmission and stability. Displacement, particularly varus collapse, significantly increases stress concentrations at the fracture site, predisposing to nonunion or fixation failure. The integrity of the posterior medial femoral neck cortex is a critical predictor of stability and healing potential for internal fixation.

Indications & Contraindications

The decision-making process for femoral neck fractures is multifactorial, balancing the patient's physiological age, activity level, bone quality, fracture pattern, and displacement. The primary goals are to achieve stable fixation or replacement, allow early mobilization, and minimize complications.

Operative Indications

• Displaced Femoral Neck Fractures (Garden Types III and IV):
  • In physiologically young patients (<60-65 years): Urgent open reduction and internal fixation (ORIF) with multiple cannulated screws or a sliding hip screw (SHS) is preferred to preserve the native hip joint, given the potential for long-term complications associated with arthroplasty. However, the high risk of AVN and nonunion (up to 30-40%) must be communicated.
  • In physiologically elderly patients (>60-65 years): Arthroplasty is generally favored.
    • Hemiarthroplasty (HA): For less active elderly patients, particularly those with significant comorbidities or pre-existing limited mobility. It offers reliable pain relief and early mobilization. Bipolar prostheses are often preferred over unipolar.
    • Total Hip Arthroplasty (THA): For active, functionally independent elderly patients with good bone quality, particularly if pre-existing osteoarthritis or inflammatory arthritis is present in the ipsilateral hip. THA offers superior functional outcomes and lower reoperation rates compared to HA but carries a slightly higher initial risk of dislocation and longer operative time.
• Non-Displaced Femoral Neck Fractures (Garden Types I and II):
  • All age groups: ORIF with multiple cannulated screws is the standard of care. Despite being "non-displaced," these fractures are prone to secondary displacement, which carries a significantly worse prognosis. Close monitoring is essential.
• Stress Fractures of the Femoral Neck: Symptomatic stress fractures, particularly on the tension side, often warrant prophylactic internal fixation to prevent complete displacement.

Non-Operative Indications

Non-operative management for femoral neck fractures is rare and typically reserved for specific circumstances:
* Medically unstable patients: Those with severe, life-limiting comorbidities precluding safe anesthesia and surgery, where the risks of surgery clearly outweigh the benefits. Palliative care and pain management become the priority.
* Non-ambulatory patients: Individuals with pre-existing neurological deficits, severe dementia, or bedridden status, where surgical intervention would not improve functional outcomes or quality of life.
* Impacted valgus fractures (Garden Type I) in extremely frail patients: While generally treated operatively, in very select, non-ambulatory, and high-risk individuals, pain control and protected weight-bearing might be considered, though this carries a high risk of secondary displacement and conversion to a more complex procedure. This approach is highly controversial.

Summary of Operative vs. Non-Operative Indications

Pre-Operative Planning & Patient Positioning

Meticulous pre-operative planning is paramount for successful outcomes and complication avoidance in femoral neck fracture management. This involves comprehensive patient assessment, imaging review, implant selection, and surgical setup.

Pre-Operative Planning

1. Medical Optimization:
   • Cardiopulmonary evaluation: Assess cardiac function (ECG, echo, cardiology consult), pulmonary status (chest X-ray, PFTs for COPD), and renal function.
   • Anemia correction: Transfusion or iron supplementation as needed.
   • Nutritional status: Optimize where possible, especially in malnourished elderly patients.
   • Diabetes control: Strict glycemic control to reduce infection risk.
   • Anticoagulation management: Bridge or discontinue according to specific protocols to minimize bleeding risk while mitigating thrombotic risk.
   • DVT/PE prophylaxis: Initiate pre-operatively (e.g., LMWH, mechanical compression devices).
   • Bone health: Assess osteoporosis and plan for post-operative management if applicable.
   • Delirium risk: Screen for delirium and implement preventive strategies.
2. Imaging Review:
   • Standard radiographs: Anteroposterior (AP) pelvis and lateral hip views are essential. Traction views can aid in assessing reducibility and true displacement.
   • CT scan: May be useful in complex cases, concomitant acetabular fractures, or if plain radiographs are equivocal, though generally not routine for simple femoral neck fractures.
   • MRI: Rarely indicated in acute settings, primarily for occult fractures or differentiating stress fractures.
3. Implant Selection and Templating:
   • Based on fracture pattern, patient age, bone quality, and surgeon preference, decide between cannulated screws, sliding hip screw (SHS), hemiarthroplasty (unipolar/bipolar), or total hip arthroplasty.
   • Templating: Utilize appropriate templates on radiographs to estimate implant size (screw length, nail diameter, stem size, head size, cup size), confirm offset, and predict leg length. This is crucial for arthroplasty, especially for component sizing and positioning.
4. Surgical Approach Selection:
   • ORIF: Typically via a minimally invasive approach with small incisions for cannulated screws.
   • Arthroplasty: Posterior, direct anterior, or anterolateral approaches, each with its advantages and disadvantages regarding dislocation risk, muscle damage, and surgical exposure. The posterior approach is widely used for its extensile exposure and familiarity.
5. Consent: Comprehensive discussion with the patient or surrogate regarding the chosen procedure, potential risks, benefits, alternatives, and expected outcomes, including the significant risks of AVN and nonunion with ORIF, and dislocation/infection with arthroplasty.

Patient Positioning

For Internal Fixation (Cannulated Screws):
* Supine on a fracture table: Essential for closed reduction and fluoroscopic guidance.
* Key elements:
* Affected leg positioned in a traction boot, allowing for controlled traction, rotation (internal/external), and abduction/adduction.
* Contralateral leg abducted to allow C-arm access.
* Perineal post positioned appropriately to provide counter-traction.
* C-arm fluoroscopy unit positioned for AP and lateral views without repositioning the patient or C-arm during the procedure. Ensure sterile draping of the C-arm.
* Image intensifier typically parallel to the floor for AP view and perpendicular to the floor for lateral view.
* Adequate padding to prevent pressure injuries.

For Arthroplasty (e.g., Posterior Approach):
* Lateral decubitus position: Patient positioned on the unaffected side.
* Key elements:
* Stabilization: Beanbag or specific positioning devices to prevent patient rolling.
* Padding: Axillary roll, padding between knees and ankles, heel protection.
* Affected hip flexed approximately 45 degrees, abducted slightly.
* Torso slightly rotated anteriorly.
* Free draping of the affected leg to allow manipulation.
* C-arm access often required for component positioning (acetabular cup inclination/anteversion, stem alignment), though often less critical than for ORIF once experience is gained.

Detailed Surgical Approach / Technique

Given the range of options, we will detail the Posterior Approach for Hemiarthroplasty/Total Hip Arthroplasty (THA) , as it is a common procedure for displaced femoral neck fractures in the elderly. We will also briefly outline the principles of ORIF for non-displaced fractures .

A. Open Reduction and Internal Fixation (ORIF) with Cannulated Screws (for Garden I/II, young displaced)

1. Reduction:
   • Achieved closed on a fracture table under fluoroscopic guidance.
   • Initial Maneuver: Apply gentle traction and internally rotate the leg to disimpact and de-rotate the distal fragment.
   • Valgus Impaction (Garden I): No reduction needed, simply stabilize.
   • Non-Displaced (Garden II): Confirm alignment.
   • Displaced (Garden III/IV):
     • Leadbetter Maneuver: Flex hip to 90 degrees, apply traction, internally rotate, and abduct. Extend hip while maintaining traction and internal rotation.
     • Gentle rocking: To achieve anatomical alignment.
     • Fluoroscopic confirmation: Ensure anatomical reduction in AP (Shenton's line intact, neck-shaft angle restored) and lateral views (no anterior/posterior displacement). A slightly valgus reduction (10-15 degrees) is acceptable and may be biomechanically advantageous. Varus malreduction is poorly tolerated.
2. Fixation:
   • Incisions: Small stab incisions laterally, distal to the greater trochanter, guided by fluoroscopy.
   • Guide wire insertion: Typically three partially threaded cannulated screws are used.
     • A central guide wire is inserted first, aiming for the infero-posterior quadrant of the femoral head (for stability).
     • Two additional guide wires are placed. A common configuration is "inverted triangle" (one superior, two inferior) or "triangle with apex superior." The screws should be parallel to each other and perpendicular to the fracture line for optimal compression, and avoid penetration of the femoral head joint space.
     • Ensure adequate depth, with screws just subchondral.
   • Drilling and Screw Placement: Drill over guide wires, measure length, and insert partially threaded cannulated screws. The partially threaded design allows for compression across the fracture site.
   • Fluoroscopic confirmation: Confirm screw position, length, and reduction stability in both AP and lateral views. Ensure no joint penetration.
3. Closure: Small subcutaneous sutures and skin staples/sutures.

B. Posterior Approach for Hemiarthroplasty or Total Hip Arthroplasty

The posterior approach is widely utilized due to its extensile exposure and relative ease for revision.

1. Incision:
   • Curvilinear incision (posterolateral), centered over the greater trochanter, extending 8-10 cm proximally along the anterior aspect of the gluteus maximus fibers and 8-10 cm distally along the posterior aspect of the femoral shaft.
   • Alternatively, a straight incision directly posterior to the greater trochanter, paralleling the femoral shaft.
2. Fascial Dissection:
   • Incise the skin and subcutaneous tissue. Identify the gluteus maximus fascia.
   • Split the gluteus maximus fibers in line with the skin incision. No internervous plane at this stage, as gluteus maximus is innervated by the inferior gluteal nerve laterally and superiorly.
   • Retract the gluteus maximus superiorly and inferiorly to expose the underlying deep structures.
3. Deep Dissection & Internervous Plane:
   • Identify the short external rotator muscles: Piriformis, superior gemellus, obturator internus, inferior gemellus, and quadratus femoris (from superior to inferior). These muscles originate from the pelvis and insert onto the greater trochanter and posterior aspect of the proximal femur.
   • The internervous plane for this approach involves splitting between the gluteus maximus (innervated by the inferior gluteal nerve) and the gluteus medius/minimus (innervated by the superior gluteal nerve). Deeper, the plane is through the detachment of the short external rotators (innervated by branches from the sacral plexus, nerve to quadratus femoris, and nerve to obturator internus) from the greater trochanter, which preserves the gluteus medius and minimus.
   • Ligate the ascending branch of the medial circumflex femoral artery, often located inferior to the piriformis and superior to the obturator internus, as it traverses the posterior hip capsule. Careful hemostasis is critical.
   • Transect the short external rotators (piriformis, gemelli, obturator internus) close to their insertions on the greater trochanter. Leave a cuff of tissue for later repair. The quadratus femoris can be partially or fully released if additional exposure is needed.
   • Incise the posterior capsule.
4. Femoral Head Removal and Acetabular Preparation:
   • Dislocation: Internally rotate the leg and apply traction while flexing the hip to dislocate the femoral head posteriorly. For a fractured femoral neck, the head may already be free within the acetabulum.
   • Femoral Head Removal: Extract the fractured femoral head.
   • Acetabular Preparation (for THA only):
     • Expose the acetabulum. Remove remaining labrum, osteophytes, and prepare the acetabular bone bed using sequential reamers. Ream until bleeding cancellous bone is exposed and the desired size is achieved, aiming for correct inclination (40-45 degrees) and anteversion (15-20 degrees).
     • Insert the trial acetabular cup, verify position and stability.
     • Insert the definitive acetabular cup (press-fit or cemented), ensuring optimal coverage and fixation. Secure with screws if needed.
5. Femoral Preparation:
   • Using a neck resection guide, resect the femoral neck at the appropriate level and angle, typically corresponding to 1 cm distal to the tip of the greater trochanter, or matching the desired leg length and offset.
   • Address any remaining fragments of the femoral neck fracture.
   • Femoral Canal Preparation: Use a femoral awl to open the medullary canal. Progressively ream or broach the femoral canal to the desired size and shape, ensuring proper alignment in both varus/valgus and anteversion. The final broach should provide firm cortical contact.
   • Trial components: Insert trial femoral stem and head.
   • Leg Length and Offset Assessment: Reduce the trial components. Assess leg length equality (anterior superior iliac spine to medial malleolus, or direct comparison of patellar heights in supine position for THA), hip stability through range of motion (flexion, internal/external rotation), and soft tissue tension. Adjust neck length/offset as needed.
   • Definitive Femoral Stem Insertion:
     • Uncemented: Insert the definitive femoral stem, ensuring a stable press-fit.
     • Cemented: Prepare the canal (lavage, drying, cement restrictor), mix bone cement, pressurize it into the canal, and insert the femoral stem. Remove excess cement.
   • Attach the definitive femoral head (bipolar head for HA, modular head for THA).
6. Reduction & Stability Testing:
   • Reduce the femoral head into the acetabular cup.
   • Perform comprehensive stability testing throughout the range of motion (flexion, adduction, internal rotation to test posterior stability; extension, abduction, external rotation to test anterior stability). Ensure no impingement or instability.
7. Closure:
   • Capsular and external rotator repair: Reattach the transected short external rotators and posterior capsule using strong, non-absorbable sutures to the greater trochanter or surrounding soft tissues. This significantly enhances posterior stability and reduces dislocation risk.
   • Fascial closure: Close the gluteus maximus fascia.
   • Subcutaneous tissue and skin closure.
   • Apply sterile dressing and post-operative splint/brace if deemed necessary (rare for posterior approach).

Complications & Management

Femoral neck fractures and their surgical treatment are associated with a range of potential complications, both general and specific. Prompt recognition and appropriate management are critical for optimizing patient outcomes.

General Complications

• Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE): High incidence in hip fracture patients due to immobility and hypercoagulable state.
  • Management: Pharmacological prophylaxis (LMWH, fondaparinux) and mechanical prophylaxis (compression stockings, intermittent pneumatic compression devices) are standard. Early mobilization is key. Symptomatic DVT requires therapeutic anticoagulation. PE can be life-threatening, requiring urgent anticoagulation or thrombolysis.
• Infection (Surgical Site Infection, SSI): Incidence varies but can be devastating.
  • Management: Meticulous sterile technique, peri-operative antibiotics (cefazolin or similar), strict glycemic control, optimizing nutritional status. Superficial SSI may be managed with wound care and oral antibiotics. Deep SSI often requires surgical debridement, implant retention if stable and early, or implant removal (Girdlestone arthroplasty, two-stage revision arthroplasty) in severe cases or chronic infections.
• Neurovascular Injury: Sciatic nerve (posterior approach, excessive traction), femoral nerve (anterior approach, retraction), lateral femoral cutaneous nerve (anterior approach). Vascular injury (femoral artery/vein) is rare.
  • Management: Careful retraction, avoidance of excessive force. Intraoperative recognition requires immediate repair. Post-operative neurological deficits require close monitoring, nerve conduction studies, and potentially exploration.
• Anesthetic Complications: Cardiopulmonary events, allergic reactions, prolonged altered mental status, delirium.
  • Management: Thorough pre-operative medical optimization, careful anesthetic choice and monitoring. Post-operative delirium prevention protocols.
• Pressure Ulcers: Due to prolonged immobility.
  • Management: Early mobilization, frequent repositioning, pressure-relieving mattresses.
• Pneumonia, UTI: Common in elderly, immobilized patients.
  • Management: Early mobilization, respiratory therapy, appropriate antibiotic treatment.

Specific Complications for Femoral Neck Fractures

Post-Operative Rehabilitation Protocols

Post-operative rehabilitation is integral to regaining mobility, functional independence, and preventing secondary complications following femoral neck fracture surgery. Protocols are tailored based on the type of surgery, patient's pre-operative status, bone quality, and surgeon's preference.

Immediate Post-Operative Period (Day 0-3)

• Pain Management: Multimodal analgesia (opioids, NSAIDs if not contraindicated, acetaminophen, regional nerve blocks) to facilitate early mobilization.
• DVT/PE Prophylaxis: Continue pharmacological and mechanical prophylaxis.
• Early Mobilization:
  • ORIF (Cannulated Screws): Initial weight-bearing status varies. Some surgeons allow immediate protected weight-bearing (toe-touch or partial weight-bearing) if fixation is stable and fracture is non-displaced. Others enforce non-weight-bearing for 6-8 weeks, especially for displaced fractures or poor bone quality, with touch-down weight-bearing for balance.
  • Hemiarthroplasty/THA (Cemented): Immediate full weight-bearing as tolerated (FWBAT) is typically permitted due to immediate implant stability.
  • Hemiarthroplasty/THA (Uncemented): FWBAT is also often allowed, but some surgeons prefer protected weight-bearing (touch-down or partial) for 4-6 weeks to allow for biological ingrowth.
• Physical Therapy (PT) Goals:
  • Bed mobility, transfers (bed to chair).
  • Initiate gentle active-assisted and active range of motion (ROM) exercises within pain limits.
  • Ambulation with appropriate assistive devices (walker, crutches).
  • Educate on hip precautions (especially for posterior approach THA: avoid hip flexion >90 degrees, adduction past midline, internal rotation). These precautions are less stringent for other approaches (e.g., direct anterior) but still warrant consideration.
• Occupational Therapy (OT): Assess and educate on activities of daily living (ADLs), use of adaptive equipment (e.g., raised toilet seat, shower chair), and home safety.
• Wound Care: Monitor for signs of infection or hematoma.

Subacute Rehabilitation (Weeks 1-6)

• Progression of Weight-Bearing: Gradually increase weight-bearing as per surgeon's protocol, progressing from protected to full weight-bearing.
• Strengthening Exercises:
  • Isometrics (quadriceps sets, gluteal sets).
  • Progressive resistive exercises for hip abductors, adductors, extensors, and flexors.
  • Knee flexion/extension, ankle pumps.
• Gait Training:
  • Progress from walker to crutches, then a single cane, and eventually independent ambulation.
  • Focus on normalizing gait pattern, improving balance, and endurance.
• ROM Exercises:
  • Continue active and passive ROM exercises to restore full hip motion, respecting any precautions.
• Functional Training:
  • Stair climbing, sit-to-stand transfers, getting in/out of a car.
• Pain Management: Transition from opioids to non-opioid analgesics.
• Bone Health Management: Initiate or continue osteoporosis treatment if appropriate.

Long-Term Rehabilitation (Weeks 6 onwards)

• Advanced Strengthening: Progress to higher-level functional exercises, sport-specific training if applicable for younger patients.
• Balance and Proprioception Training: Address fall risk, especially in the elderly.
• Endurance Training: Cycling, swimming, walking.
• Return to Activity: Gradual return to leisure activities, work, and sports as tolerated and approved by the surgeon/therapist.
• Regular follow-up: Clinical and radiological assessment to monitor healing (for ORIF), implant stability (for arthroplasty), and identify late complications.
• Patient Education: Reinforce importance of continued exercise, fall prevention strategies, and adherence to any ongoing precautions.

Summary of Key Literature / Guidelines

Evidence-based guidelines and landmark studies have significantly shaped the management of femoral neck fractures.

1. ORIF vs. Arthroplasty for Displaced Fractures in the Elderly:
   • The FAITH (Fixation Against Arthroplasty in the Treatment of Hip Fractures) trial and subsequent meta-analyses have consistently demonstrated that for displaced femoral neck fractures in the elderly , arthroplasty (HA or THA) leads to lower reoperation rates compared to ORIF. This is primarily due to lower rates of nonunion and AVN.
   • HA vs. THA in the Elderly: Multiple randomized controlled trials and systematic reviews (e.g., the HEALTH study, Cochrane reviews) generally suggest that THA offers superior functional outcomes and a lower risk of reoperation compared to HA in cognitively intact, active elderly patients with good life expectancy and minimal comorbidities. However, THA has a slightly higher risk of early dislocation. For less active or more frail elderly patients, HA remains a viable option, providing reliable pain relief and faster recovery.
2. ORIF for Non-Displaced Fractures:
   • Consensus supports ORIF with multiple cannulated screws for all non-displaced femoral neck fractures (Garden I and II) regardless of age, due to the high risk of secondary displacement with conservative management.
3. Timing of Surgery:
   • Most guidelines (e.g., AAOS Clinical Practice Guidelines for Hip Fracture in Older Adults) recommend surgery within 24-48 hours of admission, provided the patient is medically optimized. Delayed surgery is associated with increased morbidity and mortality, although medical optimization should not be rushed to the detriment of patient safety.
4. Blood Transfusion:
   • TRICC (Transfusion Requirements in Critical Care) trial and subsequent studies have informed a more restrictive transfusion strategy (hemoglobin trigger of 7-8 g/dL) in hemodynamically stable patients, demonstrating no inferiority compared to liberal strategies and potentially reducing transfusion-related risks.
5. DVT Prophylaxis:
   • Guidelines universally recommend pharmacological and mechanical DVT prophylaxis for hip fracture patients. Low molecular weight heparin (LMWH) or fondaparinux are commonly preferred agents.
6. Pain Management:
   • Multimodal analgesia, including regional nerve blocks (e.g., fascia iliaca block), is recommended to reduce opioid consumption and facilitate early rehabilitation.
7. Rehabilitation:
   • Early mobilization, often within 24 hours post-surgery, is strongly recommended across all guidelines to prevent complications and optimize functional recovery.
8. Osteoporosis Management:
   • All patients presenting with a fragility fracture should be evaluated for osteoporosis and initiated on appropriate treatment (e.g., bisphosphonates, vitamin D, calcium) to prevent future fractures.

In summary, the modern management of femoral neck fractures emphasizes prompt surgical intervention, individualized treatment selection based on patient and fracture characteristics, meticulous surgical technique, aggressive post-operative rehabilitation, and comprehensive management of medical comorbidities and osteoporosis. Adherence to these evidence-based principles is crucial for improving outcomes in this challenging patient population.