BASICERVICAL FRACTURES
Junctional Fracture | Neck-Intertrochanteric Junction | ORIF vs Arthroplasty
BASICERVICAL FRACTURE TYPES
Critical Must-Knows
- Basicervical fracture = fracture at base of femoral neck, junction between neck and intertrochanteric region
- Unstable pattern - high risk of displacement and fixation failure due to location and biomechanics
- Treatment: ORIF with DHS or cannulated screws for young/stable, arthroplasty for elderly/unstable
- Age threshold 65 years - similar to femoral neck fractures, age determines treatment approach
- High failure rate with fixation - may require conversion to arthroplasty if fixation fails
Examiner's Pearls
- "Basicervical fracture = junctional fracture between neck and intertrochanteric region
- "Unstable pattern - high risk of displacement and fixation failure
- "ORIF for young/stable (DHS or screws), arthroplasty for elderly/unstable
- "High failure rate with fixation - counsel about conversion to arthroplasty if needed
Clinical Imaging
Imaging Gallery
Critical Basicervical Fracture Exam Points
Junctional Fracture
Basicervical fracture = fracture at base of femoral neck, at the junction between neck and intertrochanteric region. Has characteristics of both femoral neck and intertrochanteric fractures. Unstable pattern with high risk of displacement.
Unstable Pattern
High risk of displacement and fixation failure due to location and biomechanics. Basicervical fractures are inherently unstable. Fixation must be secure (DHS or multiple screws). High failure rate may require conversion to arthroplasty.
Age-Based Treatment
Young (under 65) + stable: ORIF with DHS or cannulated screws (preserve native hip). Elderly (over 65) or unstable: Arthroplasty (hemi or THA). Age threshold similar to femoral neck fractures.
Fixation Options
DHS (dynamic hip screw) or cannulated screws - DHS provides better stability for unstable patterns. Cannulated screws acceptable for stable patterns. Both achieve 85-90% good results with proper technique.
Basicervical Fractures - Quick Decision Guide
| Patient | Fracture Pattern | Treatment | Outcome |
|---|---|---|---|
| Young (under 65) | Stable, minimal displacement | ORIF (DHS or screws) | 85-90% good results |
| Young (under 65) | Unstable, displaced | ORIF (DHS preferred) | 80-85% good results |
| Elderly (over 65) | Any pattern | Arthroplasty (hemi or THA) | 85-90% good results |
| Any age | Failed fixation | Conversion to arthroplasty | 80-85% good results |
BASICBasicervical Fracture Features
Memory Hook:BASIC: Base of neck fracture, Age 65 threshold, Stable = ORIF, Instability risk high, Conversion may be needed!
ORIFTreatment Decision
Memory Hook:ORIF for young/stable, Risk of failure high, Instability requires secure fixation, Fixation with DHS or screws!
FAILComplications
Memory Hook:FAIL: Fixation failure, AVN risk, Instability, Loss of reduction - high complication rate!
Overview and Epidemiology
Basicervical fractures occur at the base of the femoral neck, at the junction between the femoral neck and intertrochanteric region. They have characteristics of both femoral neck and intertrochanteric fractures, making them inherently unstable with a high risk of displacement and fixation failure.
Mechanism of Injury
Similar to femoral neck fractures:
- Low-energy fall: Elderly patients (osteoporosis)
- High-energy trauma: Young patients (motor vehicle accident, fall from height)
- Torsion: Rotational force
- Direct trauma: Less common
The basicervical region is a transition zone between the femoral neck (intracapsular) and intertrochanteric region (extracapsular). Fractures at this junction are unstable due to biomechanical forces.
Junctional Fracture
Basicervical fracture = fracture at base of femoral neck, at the junction between neck and intertrochanteric region. Has characteristics of both femoral neck (intracapsular, AVN risk) and intertrochanteric (extracapsular, instability) fractures. This makes them inherently unstable.
Epidemiology
- Incidence: 5-10% of hip fractures
- Age: Bimodal - young (high energy) and elderly (osteoporosis)
- Gender: Female predominance (osteoporosis)
- Laterality: Usually unilateral
- Associated injuries: Other fractures (10-15%), head injury (5-10%)
Anatomy and Pathophysiology
Basicervical Region Anatomy
The basicervical region:
- Location: Base of femoral neck, junction with intertrochanteric region
- Boundaries: Distal to femoral head, proximal to lesser trochanter
- Capsule: Partially intracapsular (varies)
- Blood supply: Similar to femoral neck (MFCA, retinacular vessels)
- Biomechanics: Transition zone with high stress
Transition zone characteristics:
- Proximal: Intracapsular (like femoral neck)
- Distal: Extracapsular (like intertrochanteric)
- Biomechanics: High stress concentration
- Stability: Inherently unstable
Pathophysiology
Why basicervical fractures are unstable:
- Transition zone: Junction between two regions with different biomechanics
- High stress: Stress concentration at junction
- Capsular attachment: Variable capsular attachment
- Biomechanical forces: Compression and shear forces
Blood supply:
- Similar to femoral neck: MFCA provides 80% of blood supply
- Retinacular vessels: Enter posterosuperiorly (at risk with displacement)
- AVN risk: 15-25% (lower than displaced femoral neck fractures but still significant)
Instability factors:
- Location: Transition zone
- Biomechanics: High stress concentration
- Displacement: High risk of displacement
- Fixation: High failure rate with inadequate fixation
High Instability Risk
Basicervical fractures are inherently unstable due to their location at the junction between neck and intertrochanteric region. High risk of displacement and fixation failure. Secure fixation (DHS or multiple screws) is essential. Consider arthroplasty for elderly or unstable patterns.
Classification Systems
Stability-Based Classification
Stable basicervical fracture:
- Minimal displacement (under 2mm)
- Good bone quality
- No comminution
- Treatment: ORIF with DHS or cannulated screws
- Outcomes: 85-90% good results
Unstable basicervical fracture:
- Displaced (over 2mm)
- Comminuted
- Poor bone quality
- Treatment: ORIF with DHS (preferred) or arthroplasty
- Outcomes: 80-85% good results
Stability determines treatment approach and predicts outcomes.
Clinical Assessment
History
Mechanism: Similar to femoral neck fractures
- Low-energy fall: Elderly patients (osteoporosis)
- High-energy trauma: Young patients (motor vehicle accident, fall from height)
- Torsion: Rotational force
Symptoms:
- Immediate pain in hip/groin
- Inability to bear weight
- Leg shortening and external rotation (if displaced)
- Pain with movement
Physical Examination
Inspection:
- Leg shortening (if displaced)
- External rotation (if displaced)
- Swelling (minimal - deep location)
Palpation:
- Tenderness over hip/groin
- Crepitus (rare)
- Greater trochanter tenderness
Range of Motion:
- Limited hip ROM (pain)
- Pain with passive motion
- Inability to perform straight leg raise (if displaced)
Neurovascular Status:
- Usually intact
- Assess distal pulses and sensation
Clinical Examination Key Point
Leg shortening and external rotation suggest displacement. Basicervical fractures may present similarly to femoral neck or intertrochanteric fractures. Imaging is essential for diagnosis and classification.
Associated Injuries
- Other fractures: 10-15% (wrist, spine, other hip)
- Head injury: 5-10% (high-energy trauma)
- Soft tissue injuries: Less common
Investigations
Standard X-ray Protocol
Views: AP pelvis and lateral hip.
Key findings:
- Fracture location: Base of femoral neck, junction with intertrochanteric region
- Displacement: Assess displacement (under vs over 2mm)
- Comminution: Assess for comminution
- Bone quality: Assess for osteoporosis
AP and lateral views essential - shows fracture location and displacement.
Management Algorithm
Management Pathway
Basicervical Fracture Management
Determine fracture pattern (stable vs unstable), displacement, age, bone quality, and patient factors. Assess for associated injuries.
If young and active, attempt ORIF to preserve native hip. Use DHS for unstable patterns, cannulated screws for stable patterns. Counsel about high failure rate (10-20%).
If elderly or unstable pattern, arthroplasty (hemi or THA). Hemi for low demand, THA for active. Better outcomes than fixation in elderly.
If fixation fails (10-20%), convert to arthroplasty. Outcomes good with conversion (80-85% good results).
Surgical Technique
Dynamic Hip Screw (DHS) Technique
Indications:
- Unstable basicervical fracture
- Comminuted pattern
- Poor bone quality
- Young patient with unstable pattern
Advantages:
- Better stability than cannulated screws
- Allows controlled collapse
- Lower failure rate for unstable patterns
Technique:
- Lateral approach
- Reduce fracture (anatomic reduction)
- Guide wire placement (center-center position)
- Ream for lag screw
- Insert lag screw (optimal position)
- Attach side plate
- Fix with screws
- Confirm reduction and stability
DHS provides better stability for unstable basicervical fractures.
Complications
| Complication | Incidence | Risk Factors | Prevention/Management |
|---|---|---|---|
| Fixation failure | 10-20% | Unstable pattern, poor fixation | Secure fixation (DHS), consider arthroplasty |
| AVN | 15-25% | Displacement, delayed fixation | Early fixation, anatomic reduction |
| Nonunion | 10-15% | Inadequate fixation, poor reduction | Secure fixation, good apposition |
| Displacement | 15-20% | Unstable pattern, inadequate fixation | Secure fixation (DHS), protected weight bearing |
| Conversion to arthroplasty | 10-20% | Failed fixation | Arthroplasty for high-risk cases |
Fixation Failure
10-20% incidence:
- Cause: Unstable pattern, inadequate fixation, poor bone quality
- Prevention: Secure fixation (DHS for unstable), consider arthroplasty for high-risk cases
- Management: Conversion to arthroplasty
AVN
15-25% incidence:
- Cause: Displacement, delayed fixation, disruption of blood supply
- Prevention: Early fixation (within 24-48 hours), anatomic reduction
- Management: Conversion to arthroplasty if symptomatic
Nonunion
10-15% incidence:
- Cause: Inadequate fixation, poor reduction, poor bone quality
- Prevention: Secure fixation, good bone apposition
- Management: Revision fixation or conversion to arthroplasty
Postoperative Care
Immediate Postoperative
- Immobilization: None (early mobilization)
- Weight bearing: Depends on fixation
- DHS: Touch-down weight bearing for 6-8 weeks
- Cannulated screws: Touch-down weight bearing for 6-8 weeks
- Arthroplasty: Weight-bearing as tolerated
- ROM: Early hip ROM (immediate)
- PT: Hip ROM, strengthening
Rehabilitation Protocol
Weeks 0-2:
- Touch-down weight bearing (if ORIF)
- Hip ROM exercises
- Quadriceps and hip strengthening
- Ice and elevation
Weeks 2-6:
- Progressive weight bearing (if ORIF)
- Continue ROM and strengthening
- Balance and proprioception
Weeks 6-12:
- Full weight bearing (if ORIF)
- Progressive activity
- Sport-specific training (if applicable)
Weeks 12+:
- Return to sport (when strength and ROM normal)
- Continue PT as needed
Return to Sport
Criteria:
- Full ROM (equal to contralateral)
- Strength greater than 90% of contralateral
- No pain or instability
- Functional testing passed
Timeline: Usually 3-6 months postoperatively, depending on fixation and healing.
Outcomes and Prognosis
Overall Outcomes
ORIF outcomes:
- Success rate: 80-90% (lower than standard intertrochanteric fractures)
- Functional outcomes: 75-85% return to pre-injury level
- Complications: 20-30% (fixation failure, AVN, nonunion)
Arthroplasty outcomes:
- Success rate: 85-90% (better than ORIF for elderly)
- Functional outcomes: 80-85% return to pre-injury level
- Complications: 10-15% (dislocation, infection, loosening)
Functional Outcomes
Return to sport:
- Timeline: 3-6 months postoperatively
- Rate: 75-85% return to pre-injury level
- Factors: Age, fixation type, rehabilitation compliance
Functional testing:
- Hip strength: 90%+ of contralateral
- ROM: Full (if no complications)
- No pain or instability
Long-Term Prognosis
Fixation failure risk:
- ORIF: 10-20% (higher than standard intertrochanteric fractures)
- Conversion to arthroplasty: 10-20% (if fixation fails)
- Arthroplasty: 5-10% revision at 10 years
AVN risk:
- ORIF: 15-25% (similar to displaced femoral neck fractures)
- Arthroplasty: Not applicable (head removed)
Factors Affecting Outcomes
Positive factors:
- Stable pattern
- Good bone quality
- Early fixation (within 24-48 hours)
- Secure fixation (DHS for unstable)
- Complete rehabilitation
Negative factors:
- Unstable pattern
- Poor bone quality
- Delayed fixation
- Inadequate fixation
- Incomplete rehabilitation
Prevention and Return to Sport
Prevention
Primary prevention:
- Osteoporosis treatment (bisphosphonates, denosumab)
- Falls prevention programs
- Balance and strength training
- Home safety modifications
Secondary prevention (after injury):
- Complete rehabilitation before return to sport
- Continued strength and conditioning
- Gradual return to activity
Return to Sport Criteria
Clinical:
- Full ROM (equal to contralateral)
- Strength greater than 90% of contralateral
- No pain or instability
Functional:
- Single-leg hop test (greater than 90% of contralateral)
- Agility testing passed
- Sport-specific drills completed
Timeline: Usually 3-6 months postoperatively, depending on fixation and healing.
Evidence Base
Basicervical Fracture Characteristics
- Junctional fracture between neck and intertrochanteric region
- Inherently unstable pattern with high risk of failure
ORIF Outcomes
- DHS provides better stability than cannulated screws
- High failure rate (10-20%) may require conversion
Arthroplasty Outcomes
- Better outcomes than fixation in elderly patients
- Hemiarthroplasty for low demand, THA for active
Fixation Failure Risk
- DHS provides better stability than cannulated screws
- Consider arthroplasty for high-risk cases
Age-Based Treatment
- Young (under 65): ORIF to preserve native hip
- Elderly (over 65): Arthroplasty for better outcomes
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Young Patient with Basicervical Fracture
"A 45-year-old active man presents after a motor vehicle accident. He has a painful hip and cannot bear weight. X-ray shows a basicervical fracture with 3mm displacement. He is otherwise healthy and active."
Scenario 2: Elderly Patient with Unstable Basicervical
"A 75-year-old woman presents after a fall. She has a painful hip and cannot bear weight. X-ray shows a comminuted basicervical fracture with significant displacement. She has osteoporosis and multiple comorbidities."
MCQ Practice Points
Basicervical Fracture Location
Q: Where does a basicervical fracture occur? A: Base of femoral neck, at the junction between neck and intertrochanteric region - Has characteristics of both femoral neck (intracapsular, AVN risk) and intertrochanteric (extracapsular, instability) fractures.
Instability
Q: Why are basicervical fractures unstable? A: Junctional fracture at transition zone - High stress concentration at junction between neck and intertrochanteric region. Inherently unstable pattern with high risk of displacement and fixation failure (10-20%).
Treatment for Young Patient
Q: What is the treatment for a basicervical fracture in a young patient (under 65)? A: ORIF with DHS or cannulated screws - Attempt to preserve native hip. DHS preferred for unstable patterns, cannulated screws for stable patterns. High failure rate (10-20%) may require conversion to arthroplasty.
Treatment for Elderly Patient
Q: What is the treatment for a basicervical fracture in an elderly patient (over 65)? A: Arthroplasty (hemi or THA) - Better outcomes than fixation in elderly (85-90% vs 60-70%). Hemiarthroplasty for low demand, THA for active. Age threshold similar to femoral neck fractures.
Fixation Failure Risk
Q: What is the failure rate of ORIF for basicervical fractures? A: 10-20% - Higher than standard intertrochanteric fractures due to instability. DHS provides better stability than cannulated screws for unstable patterns. May require conversion to arthroplasty if fixation fails.
DHS vs Cannulated Screws
Q: When is DHS preferred over cannulated screws for basicervical fractures? A: Unstable patterns - DHS provides better stability than cannulated screws for unstable, displaced, or comminuted basicervical fractures. Cannulated screws acceptable for stable, non-displaced patterns.
Australian Context
Clinical Practice
- Basicervical fractures common in hip fractures
- ORIF for young/stable, arthroplasty for elderly/unstable
- DHS preferred for unstable patterns
- Early surgery emphasized (within 24-48 hours)
Healthcare System
- ORIF and arthroplasty covered under public system
- Public hospitals handle most cases
- Private insurance covers procedures
- Physiotherapy accessible through public/private
Orthopaedic Exam Relevance
Basicervical fractures are a common viva topic. Know that basicervical = junctional fracture (unstable), ORIF for young/stable (DHS preferred for unstable), arthroplasty for elderly/unstable (better outcomes), high failure rate (10-20%), and age threshold 65 years (similar to femoral neck fractures). Be prepared to discuss surgical technique and complications.
BASICERVICAL FRACTURES
High-Yield Exam Summary
Key Anatomy
- •Basicervical region: Base of femoral neck, junction with intertrochanteric region
- •Transition zone: Has characteristics of both neck and intertrochanteric fractures
- •Blood supply: Similar to femoral neck (MFCA 80%, retinacular vessels)
- •Biomechanics: High stress concentration at junction
Classification
- •By stability: Stable (ORIF), Unstable (DHS or arthroplasty)
- •By age: Young (under 65) = ORIF, Elderly (over 65) = arthroplasty
- •By displacement: Non-displaced (ORIF), Displaced (DHS or arthroplasty)
- •By comminution: Simple (ORIF), Comminuted (Arthroplasty)
Treatment Algorithm
- •Young (under 65) + stable: ORIF with DHS or screws - 85-90% good results
- •Young (under 65) + unstable: ORIF with DHS (preferred) - 80-85% good results
- •Elderly (over 65): Arthroplasty (hemi or THA) - 85-90% good results
- •Failed fixation: Conversion to arthroplasty - 80-85% good results
Surgical Pearls
- •DHS preferred for unstable patterns (better stability than screws)
- •Cannulated screws acceptable for stable patterns
- •Arthroplasty for elderly/unstable (better outcomes than fixation)
- •Timing: Within 24-48 hours (similar to femoral neck fractures)
Complications
- •Fixation failure: 10-20% (higher than standard intertrochanteric)
- •AVN: 15-25% (similar to displaced femoral neck fractures)
- •Nonunion: 10-15% (prevent with secure fixation)
- •Conversion to arthroplasty: 10-20% (if fixation fails)