Outcomes after initial nonoperative management of undisplaced intracapsular femoral neck fractures: a five-year single-center cohort study with structured literature review.

BACKGROUND

Early surgical fixation is the standard approach for intracapsular femoral neck (neck of femur; NOF) fractures. However, a small subgroup of patients is managed conservatively because operative risks outweigh benefits, or due to patient preference. We evaluated outcomes of initial nonoperative management in older adults and contextualised our findings through a structured literature review.

METHODS

We conducted a retrospective observational cohort study at a UK tertiary orthopaedic trauma unit (January 2018-August 2023). Patients with undisplaced or valgus-impacted NOF fractures initially managed nonoperatively, were included. The primary outcome was treatment failure, defined as conversion to operative fixation or arthroplasty. Secondary outcomes included 30- and 90-day mortality, and treatment-related complications.

RESULTS

38 patients were analysed. Most fractures were AO/OTA type 31-B1 (n = 29/38). The majority of patients were ASA class II-III (n = 14 and n = 15, respectively). 13 patients required delayed surgery (34%; 95% CI 21-50%), most commonly hemiarthroplasty (n = 9), followed by total hip arthroplasty (n = 3) and dynamic hip screw fixation (n = 1). The mean time from injury to surgery in those converted was 49 days (range 1-208). Of the 25 patients remaining nonoperative, 14 had no fracture-related readmissions, while two had persistent pain or poor mobility. 30-day mortality was 18% (7/38), and the 90-day mortality was 24% (9/38).

CONCLUSION

Initial nonoperative management can avoid surgery in selected patients but carries a substantial risk of delayed conversion and prolonged time to definitive fixation. If chosen, a standardised pathway with close clinical and radiographic follow-up and clear escalation triggers is essential.