Neck of Femur (NOF) fractures
Fractured neck of femur is a common and clinically important ED presentation, most often seen in older adults after a low‑energy fall. It carries high short‑term morbidity and mortality and significant risk of loss of independence.
Rapid, protocolised ED assessment, timely analgesia (including regional techniques), prompt imaging and pathway activation for orthopaedic and orthogeriatric care improve outcomes (NICE CG124; RCEM toolkit; NICE QS16).
Epidemiology and significance
- Peak incidence in older people with osteoporosis after low‑mechanism falls.
- Younger patients may suffer NOF fractures after high‑energy trauma or with bone disease (metastatic disease, osteomalacia, hyperparathyroidism).
- Key complications: avascular necrosis (AVN), non‑union (particularly intracapsular), thromboembolism, chest infection, delirium, and functional decline.
- UK quality frameworks (NICE, NHFD, Best Practice Tariff) prioritise rapid assessment, early analgesia, timely imaging, orthogeriatric input and surgery on the day of or the day after admission (NICE QS16).
Pathophysiology and blood supply
- Classify clinically as intracapsular (femoral neck within the hip capsule) or extracapsular (intertrochanteric or subtrochanteric).
- The femoral head blood supply is mainly from retinacular vessels (ascending cervical branches of the medial and lateral femoral circumflex arteries).
- Intracapsular fractures can disrupt femoral head blood supply → increased risk of AVN and non‑union.
- Extracapsular fractures typically preserve femoral head perfusion and are more commonly treated with head‑preserving fixation.