Fractured Truths: A Collected Review of Modern Insights on Femoral Neck Fracture Management

Abstract

Femoral neck fractures (FNFs) remain one of the most devastating injuries in adult patients, associated with a high morbidity, mortality and economic burden worldwide. The global incidence of hip fractures exceeds 1.6 million annually and is projected to rise to between 4.5 and 6.5 million by 2050. FNFs account for approximately 50% of all hip fractures and are strongly associated with aging, osteoporosis and frailty. Mortality rates remain high, approaching 10% within the first month and up to 36% within one year of injury. While displaced FNFs are widely managed with arthroplasty, the role of internal fixation (IF) in minimally displaced fractures is controversial, particularly in the context of emerging evidence highlighting high significant reoperation rates after fixation. Current treatment pathways must balance functional recovery, risk of complications such as dislocation, periprosthetic fracture and infection with long-term implant survivorship. Evolving strategies include utilising dual mobility (DM) total hip arthroplasty (THA) to mitigate instability and registry-based comparisons that refine patient selection criteria for hemiarthroplasty (HA) versus THA. Classification systems such as Garden, Pauwels, and AO/OTA remain central to guiding treatment, though their reliability is limited, and simplified displaced/undisplaced categorization improves interobserver agreement. This review synthesises contemporary evidence across epidemiology, surgical timing, classification, fixation versus arthroplasty, innovations in implant design, complications, outcomes, and policy implications, integrating registry analyses, randomised trials, and systematic reviews.