David G Levelle

Gulam Nabi Dar

HH Banks

Khursheed Ahmed Kangoo

L Hernefalk

Mark Jackson

MF Butt

Mohammed Farooq Butt

Mudassir Maqbool Wani

MW Chapman

Naseem Ul Gani

S Holmberg

WB Arnold

English

PubMed

Crossref

More than two years delay in the union of fracture neck of femur after primary intervention

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BioMed CentralCases Journal
ssOpen AcceCase Report
More than two years delay in the union of fracture neck of femur 
after primary intervention
Naseem Ul Gani*1, Khursheed Ahmed Kangoo1, Mohammed Farooq Butt1, 
Gulam Nabi Dar1 and Mudassir Maqbool Wani2
Address: 1Department of orthopedics, Govt hospital for bone and joint surgery Barzullah, Srinager, India and 2Department of surgery, GMC, 
Srinagar, India
Email: Naseem Ul Gani* - naseemulgani@gmail.com; Khursheed Ahmed Kangoo - kakangoo@gmail.com; 
Mohammed Farooq Butt - mfbutt72@yahoo.co.in; Gulam Nabi Dar - gulamnabidar@gmail.com; 
Mudassir Maqbool Wani - mudds_123@yahoo.co.in
* Corresponding author    
Abstract
Introduction: More than two years delay in the union of fracture neck of femur is a very rare
entity.
The treatment of an established non union depends on numerous factors including age of the
patient, vascularity of the femoral head and other factors. It is timing of intervention that is not
clearly defined in the literature.
Case presentation: We report 2 cases where fracture neck of femur in 2 Asian males of 37 and
52 years of age took more than 2 years to unite after primary intervention.
Conclusion: We believe if the implant is holding and patient is able to bear some weight, some of
these fractures may unite without any further intervention.
Background
The standard treatment for displaced fracture of neck of
femur in young adults is internal fixation, aimed at salvag-
ing the femoral head [1]. Nonunion is a frequent compli-
cation of intracapsular fractures of the femoral neck
because healing of a fracture neck of femur is different
from other long bones. Blood supply is precarious which
is further jeopardized by displacement of fragments and
tamponade effect adds to the insult by occluding the veins
at lower pressure and arteries at higher pressure. Because
of the elongated position of the femoral neck within cap-
sule and absence of cambium layer of periostium [2], the
fracture neck of femur heals without external callous.
Being intracapsular it is bathed by synovial fluid. Com-
mon to all intracapsular fractures, the synovial fluid bath-
ing the fracture may interfere with healing process.
Angiogenic inhibiting factors can also inhibit fracture
repair [3]. In combination all these factors lead to compli-
cations like nonunion, avascular necrosis and segmental
collapse of the femoral head [4]. The stability of the fixa-
tion depends on the accuracy of reduction, the implant
used and density of the bone [5]. Non union may occur
where fixation stability has been compromised by poor
surgical technique [6]. Nonunion can be diagnosed
within 12 months of fracture fixation [5]. After nonunion
has been established, intervention is inevitable. We report
2 cases of nonunion fracture neck of femur who refused
further intervention at one year after fracture fixation and
Published: 25 July 2008
Cases Journal 2008, 1:61 doi:10.1186/1757-1626-1-61
Received: 6 June 2008
Accepted: 25 July 2008
This article is available from: http://www.casesjournal.com/content/1/1/61
© 2008 Ul Gani et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
Cases Journal 2008, 1:61 http://www.casesjournal.com/content/1/1/61were allowed to continue with partial weight bearing as
the implant was holding. Both patients consented to a reg-
ular follow up and were supervised carefully. Both frac-
tures ultimately united after 2 years.
Case reports
Case no 1
A 38 year old Kashmiri male businessman with displaced
fracture neck of femur was admitted in our hospital. He
was operated within 48 hours. A good reduction and fixa-
tion was achieved using 3 AO 6.5 mm cannulated screws.
Patient was allowed partial weight bearing as per pain tol-
erance in post operative period. At 6 months patient com-
plained of a persistent groin pain on ambulation.
Radiographs at 6 months showed nonunion. Patient was
supervised till one year with the hope that the fracture
might unite. But radiographs at one year showed clear cut
gap at fracture site and there was no progress towards frac-
ture healing. However there was no malalignment or
shortening. Implant was holding and had not displaced.
Head sphericity was maintained and there was no loss of
articular cartilage space. At this time surgical options were
discussed with the patient. As patient had mild pain, he
refused surgery and preferred to use a stick and consented
to 2 monthly follow up. After 26 months of fracture fixa-
tion patient's pain subsided and radiograph at 32 months
showed full union. The patient at this moment was
assymptomatic, had good range of motion around hip
and knee and had no shortening.
Case no 2
A 52 year old Kashmiri male farmer from a far flung area
of our state reported to our hospital 6 days after sustaining
fracture neck of left femur. Patient was operated within 2
days. Closed reduction and internal fixation was done
using three cannulated screw (Fig. 1). In this patient as a
result of surgical error, screws were not parallel in lateral
view. After discharge from the hospital, patient was lost in
follow up for 6 months. At 6 months patient had pain in
the affected hip on weight bearing. Radiographs showed
that the fracture had displaced from its original position
and had varus angulation (Fig. 2). Since the implant was
holding patient was advised touch down weight bearing.
Patient was discharged and asked for a regular follow up
every 2 months. At one year patient was bearing partial
weight on the limb and was using a stick. Clinically
patient had pain in the affected hip on weight bearing.
Radiographs showed no further displacement of the frac-
ture though there was a gap at the fracture site. Patient
refused any surgical intervention at this time and agreed
to a regular follow up. Over a period of one year patients
symptoms improved and radiographs after 29 months of
fracture fixation showed union (Fig. 3). Patient had no
pain on weight bearing and had a good range of motion
of affected hip and ipsilateral knee though he had short-
ening of 1.5 cm.
Discussion
The standard treatment for displaced fracture of the femo-
ral neck in young adults is internal fixation, aimed at sal-
vaging the femoral head [1]. Rate of non union in fracture
neck of femur has been reported to be 2 to 22% and gen-
erally becomes apparent within one year [2,7-9]. Delayed
Case no 2, radiograph at 6 months, showing displacementFigure 2
Case no 2, radiograph at 6 months, showing displace-
ment.
Case no 2, immediate Post operative radiograph AP viewFigure 1
Case no 2, immediate Post operative radiograph AP 
view.Page 2 of 3
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union or nonunion often manifests as continued pain
localized to the groin and over anterolateral aspect of
injured hip aggravated by weight bearing. The treatment
of an established nonunion depends on numerous factors
including the age of the patient, vascularity of the femoral
head; alignment of the neck and shaft and potential limb
length discrepancy [5]. However timing of such an inter-
vention is not clearly defined in the literature. In elderly
symptomatic patients preferred treatment is endopros-
thetic replacement. In the young adults, femoral head sal-
vage is almost always indicated [1]. There are numerous
surgical procedures to achieve union with preservation of
the femoral head. Replacement of cancellous screws with
a larger screw may be considered in the absence of mala-
lignment, shortening, loss of reduction and avascular
necrosis [5]. This could have been the treatment of case no
1 at one year. Since patient refused surgery at one year, we
had no option but to continue with supervised neglect of
the patient. This case demonstrated as long as the implant
is holding, good results may be achieved even after two
years of fracture fixation.
Fixation combined with proximal femoral osteotomy is
indicated in the treatment of nonunion with shortening
or varus angulation [5]. This could have been the treat-
ment of case no 2. Again patient refused surgery, so we
had to continue with conservative treatment. This case
demonstrated that fracture neck of femur which had dis-
placed after fixation can still unite though it can delay up
to 2 years.
Conclusion
We conclude that as long as implant is holding, patient is
able to bear some weight and patient is ready for a regular
follow up, union can be achieved even after 2 years of fix-
ation of a fracture neck of femur without any further inter-
vention.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
NUG designed the study, wrote the manuscript, per-
formed literature review, KAK, MFB, GND, MMW helped
in literature review and drafting the final manuscript. All
authors read and approved the final manuscript.
Consent
Written informed consent was obtained from the patients
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
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Case no 2, radiograph showing union at 29 monthsFigure 3
Case no 2, radiograph showing union at 29 months.Page 3 of 3
(page number not for citation purposes)


Factors influencing the results in fractures of the femoral neck.

Fractures of the hip. In campbell's operative orthopedics Volume 3. 10th edition.

Kawoosa AA: Delayed fixation of displaced femoral neck fractures in younger adults. Injury

KG: Treatment and outcome of femoral neck fractures:An analysis of 2418 patients admitted from their own homes. Clin Orthop Relat Res

learmonth Ian D: The treatment of non union after intracapsular fracture of the proximal femur. Clinical orthopedics and related research

Nonunion in fractures of the femoral neck. Orthop Clin North Am

Rigid osteosynthesis decreases the late complication rate after femoralneck fracture. The influence of three different osteosynthesis devices evaluated in 369 patients. Arch Orthop Trauma Surg

Treatment of intracapsular fractures of the femoral neck.

Treatment of intracapsular hip fractures by Deyerle method.

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More than two years delay in the union of fracture neck of femur after primary intervention

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