Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Femoral Neck


Medical Codes

ICD-9-CM:
820.00 - Closed Fracture of Intracapsular Section of Neck of Femur, Unspecified
820.01 - Closed Fracture of Epiphysis of Neck of Femur
820.02 - Closed Fracture of Mid-cervical Section of Neck of Femur
820.03 - Closed Fracture of Base of Neck of Femur, Cervicotrochanteric Section
820.09 - Closed Transcervical Fracture of Neck of Femur, Other
820.10 - Open Fracture of Unspecified Intracapsular Section of Neck of Femur
820.11 - Open Fracture of Epiphysis of Neck of Femur
820.12 - Open Fracture of Mid-cervical Section of Neck of Femur
820.13 - Open Fracture of Base of Neck of Femur
820.19 - Open Transcervical Fracture of Femur, Other
820.8 - Closed Fracture of Neck of Femur, Unspecified Part
820.9 - Open Fracture of Neck of Femur, Unspecified Part

Related Terms

  • Broken Hip
  • Hip Fracture
  • Intracapsular Fracture of the Femoral Neck
  • Pauwel's Fracture
  • Unsolved Fracture

Overview

© Reed Group
A femoral neck fracture is a hip fracture in which the neck of the thigh bone (femur) is partially or completely broken. Femoral neck fractures may occur as a result of a fall or motor vehicle accident, or they may occur spontaneously because of a disease process such as osteoporosis. Stress fractures can result from repetitive mechanical stress or structural defects in the bone that make it weak or brittle. Femoral neck fractures in the elderly may occur spontaneously or following low-velocity trauma; in young adults, femoral neck fracture usually is caused by high-velocity trauma. Conditions that predispose to femoral neck fracture include diabetes, osteoporosis (particularly in postmenopausal women), softening of the bones (osteomalacia), cancer that has metastasized to the bone, rheumatoid arthritis, neurological disease, previous hip fracture, hyperparathyroidism associated with severe renal disease and maternal history of hip fracture.

A complete fracture is described as the femoral neck no longer being intact. A displaced fracture of the femoral neck, usually caused by trauma, refers to a condition where the bone has been moved out of its original position resulting in the two adjoining bone fragments failing to line up. Another potential scenario for a displaced fracture is a femoral neck bone fragment having rotated about its axis. If a stress fracture goes unrecognized, it can progress to a complete fracture and displace.

Fractures of the femoral neck are divided into four types according to the Garden system, which describes fractures according to their degree of completeness and displacement. Garden Type I fracture is incomplete or twisted (valgus impacted); Type II is complete but not displaced; Type III is complete and partially displaced; and Type IV is complete and totally displaced. Type I fractures are considered stable, while the other classes of fractures are considered unstable. An impacted fracture, in which the surfaces are crushed together, must be distinguished from a nondisplaced fracture. A nondisplaced fracture has no impaction and no inherent instability.

Incidence and Prevalence: It is estimated that 250,000 hip fractures occur in the US each year (Malanga). This figure is expected to double within the next 30 years (Auron-Gomez). Incidence of hip fracture in individuals aged 65 and older is 818 per 100,000. Women are affected 2 to 3 times more often than men (Auron-Gomez). Stress fractures of the femoral neck are more common in women and comprise 5% to 10% of all stress fractures (Malanga); the prevalence of hip fracture, regardless of location, is highest among women of European ancestry, followed by men of European ancestry, women of African ancestry, and men of African ancestry (Malanga).

Source: Medical Disability Advisor



Diagnosis

History: The physician will take a complete health history, including previous fractures, chronic diseases, and medications. With athletes and dancers, the physician may ask about training regimens and changes in training activities. The most prominent symptom individuals report is pain in the hip, groin, or thigh, usually following a fall or accident. Hip pain associated with a displaced fracture is typically more severe than with a nondisplaced fracture. Pain is sometimes felt in other areas of the body, such as the knee (referred pain). In addition, the individual may report swelling (edema), point tenderness, paleness (pallor), a tingling sensation (paresthesia) in the limb, paralysis, deformity, discoloration, grating sound upon movement (crepitus), and loss of mobility or range of motion.

Physical exam: The exam usually reveals tenderness and edema in the affected area, decreased ability or inability to move, and groin pain with hip motion. The affected leg may look shorter than the intact leg or appear to be bent (flexed) and turned outward (externally rotated) if the fracture has displaced. There may be associated bruising, discoloration, and loss of pulse in the affected leg. Reflexes in the affected leg may be compared with reflexes in the other (contralateral) leg to detect loss of sensation. If the fracture is open, an obvious skin wound will be present.

Tests: X-rays of the hip, pelvis, femur, knee, and other tender or painful areas are done to determine the extent of the hip fracture and whether or not secondary fractures are present. MRI may also be used if a suspected fracture, especially a stress fracture, is not readily visible on plain x-rays. A bone scan may be done to rule out a bone tumor, confirm a suspected fracture, or assess whether the femoral head has impaired blood supply because of the fracture. If surgery is indicated, routine laboratory blood and urine tests will be done before surgery, including complete blood count (CBC), chemical profile, blood clotting profile, and electrolytes. Chest x-ray and electrocardiogram (ECG) are usually done to assess the risk of receiving anesthesia.

Once treatment and recovery are underway, previously mobile individuals with underlying osteoporosis may undergo bone density testing (bone densitometry) as part of their evaluation for long-term therapy.

Source: Medical Disability Advisor



Treatment

Femoral neck fractures are treated as emergencies because the consequences of delaying treatment can be severe, even life-threatening. Gentle traction may be used during transport to the hospital. The leg should be immobilized or splinted, a cold pack applied, and the leg elevated to reduce pain and swelling. Open wounds are cleaned, a tetanus vaccination is given, and antibiotics are administered.

Surgical repair of the fracture is nearly always indicated and is performed as soon as possible after the injury. Nonoperative management (bed rest followed by early mobilization) may be appropriate for certain elderly individuals who were sedentary prior to fracture and who are not experiencing significant pain. Nondisplaced fractures usually are treated by fixation with 3 to 4 screws, which may be inserted through the skin. Treatment of displaced fractures is directed at preservation of life and restoration of hip function. Displaced fractures usually are treated by re-aligning the bones in their anatomically normal position and using internal fixation (screws, pins, and / or a plate) to maintain normal alignment to the bone fragments (open reduction, internal fixation [ORIF]). In elderly individuals, the rounded portion of the ball and socket joint in the affected hip may be replaced by a prosthetic (hemiarthroplasty). Hip hemiarthroplasty is normally reserved for Type IV displaced fractures and in cases in which there was a pre-existing abnormal condition such as arthritis. Total hip replacement (arthroplasty), which also replaces the socket portion of the hip joint, may be required in some cases, such as when active individuals sustain a fracture of a hip with pre-existing significant arthritis, (See Total Hip Replacement.) Individuals with femoral neck fractures secondary to irradiation are treated using internal fixation devices, although hemiarthroplasty may also be performed.

Individuals are encouraged to get up and walk as soon as possible following surgery to prevent complications such as deep vein thrombosis, pulmonary embolism, bedsores, and pneumonia due to prolonged immobilization. Plain x-rays are taken of the hip every 8 to 12 weeks until the fracture has healed completely. Osteoporosis, which is often present, is treated with calcium supplementation and bone-preserving drugs.

Source: Medical Disability Advisor



Prognosis

The prognosis for individuals experiencing a femoral neck fracture is extremely variable, depending on the type of injury, presence of pre-existing conditions, age of the individual, and treatment required. Some individuals fully recover following a hip fracture, while most lose a degree of function. Long-term prognosis for elderly individuals treated with ORIF varies. After two years, about 42% of elderly individuals experience complications and 47% require additional surgery (Malanga). The mortality rate at one year among elderly patients with hip fracture ranges from 14% to 36%. Overall, one in four hip fracture patients will die within one year of injury (Auron-Gomez).

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation of femoral neck fracture involves physical therapy designed to promote ambulation, increase range of motion, and improve muscle strength. Therapy will depend on the method used to stabilize the fracture, such as closed reduction percutaneous pinning, open reduction and internal fixation (nailing), or (partial) joint replacement (LaVelle). There is no benefit for pre-operative traction (Oliver). Dietetic assistance may improve recovery in older individuals (Avenell; Oliver; Khan). In some cases, bisphosphonates may be needed to facilitate bone regrowth during recovery (Hegmann, "Hip and Groin Disorders - Hip fracture [Medications]").

The primary goal of rehabilitation is early mobilization which includes ambulation and resumption of activities of daily living (Koval). To achieve this goal the individual may require assistive devices for gait training with weight bearing determined by the physician's protocol. Ideally, partial to full weight bearing can be expected immediately after surgery (Koval). The progression from walker to crutches to cane is based on weight bearing status, balance, and strength. Some older individuals may require transfer to rehabilitation facilities to receive inpatient physical therapy prior to home discharge.

The pre-operative status of the individual and physician protocol will dictate the amount of reconditioning needed after surgery. Refer to Total Hip Replacement for details on recovery following partial joint replacement. Individuals with internal fixation are usually able to begin partial weight bearing early, depending on the extent of the surgery (LaVelle). For many individuals who sustain a femoral neck fracture, gait and transfer training will be sufficient to regain their preoperative status. General conditioning of the upper extremities and uninvolved lower extremity may help to facilitate early mobilization and transfers. Ankle range of motion exercises of the involved extremity promotes circulation. Aquatic therapy may be useful for some individuals who do not progress with land therapy (Bartels). Insufficient evidence exists regarding the need for targeted reconditioning of the involved lower extremity (Handoll); however, postoperative therapy emphasizing strengthening and cardiovascular fitness is recommended for those with persistent weakness (Hegmann, "Hip and Groin Disorders - Hip fracture [Activity Modification]"). The goal is to achieve full range of motion, strength, and balance in the involved leg.

Additional information may provide greater insight into the rehabilitation needs of these individuals (Cameron; Handoll).

FREQUENCY OF REHABILITATION VISITS
Surgical
SpecialistFracture, Femoral Neck
Physical TherapistInpatient: daily
Physical TherapistOutpatient: up to 8 visits within 4 weeks
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

Complications associated with a femoral neck fracture increase with age and include muscle contractures, and the possibility of permanent deformity and dysfunction if the bones fail to heal (nonunion) or heal incorrectly (malunion). Complications are more likely if diagnosis of a femoral neck stress fracture is delayed (Auron-Gomez). Early fixation failure (within 3 months of surgery) occurs in 12% to 24% of femoral neck fractures treated with internal fixation (Malanga). Nondisplaced fractures may become displaced prior to treatment. High-velocity femoral neck fractures are often associated with other injuries including pelvis fracture, knee injuries, and chest contusions following a motor vehicle accident, and with wrist, shoulder, and rib fractures following a major fall.

Femoral neck fracture can disrupt the blood supply to the femoral head (avascular necrosis or osteonecrosis of the femoral head) with subsequent collapse and arthritis of the hip. Incidence of osteonecrosis correlates with the severity of the original fracture, the degree of displacement, and ultimately with the adequacy of internal reduction and fixation. Inadequately reduced fractures, where the fractured bones remain out of alignment despite treatment are particularly prone to osteonecrosis (LaVelle). These cases manifest as late pain and stiffness beginning months after the fracture. Approximately 20% of femoral neck fractures ultimately require a prosthetic replacement due to osteonecrosis or nonunion of fracture (LaVelle).

Prolonged immobility can lead to kidney stones (renal calculi), blood clots (thromboembolism), pneumonia, or bed sores. Especially in the elderly, these complications can be life threatening. Even in younger individuals, fat released from the broken bone (fat embolism) can enter the bloodstream, causing stroke or even death. Some individuals may over time develop degenerative or post-traumatic arthritis in the hip.

Elderly individuals may experience some degree of temporary mental deterioration following femoral neck fracture surgery caused by undetermined factors that may include general anesthesia, depression, or awareness of age-related changes.

Source: Medical Disability Advisor



Factors Influencing Duration

Factors influencing length of disability include the location and type of fracture; the cause of the fracture; the presence of any underlying diseases or pathologic conditions that precipitated the fracture; the specific treatment or surgical intervention provided; the development of complications; and the individual's age, general health, and ability to ambulate after surgery. Individual job requirements, and whether individual performs work while seated or standing, also affect length of disability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals requiring surgical intervention may require a leave of absence. Because of the extensive physical therapy that may be needed, additional time off may be required. Moderate (50 pounds) lifting may be prohibited for at least 1 year to observe for avascular necrosis of the femoral head. Individuals whose jobs require prolonged standing may need temporary reassignment to sedentary duties. If crutches are prescribed, relocation to an accessible area of the workplace may be required, along with additional safety precautions. Walking canes or walkers may be necessary to aid individuals with an unsteady gait, and rails should be installed in the bathroom and on stairs as precautionary measures to help prevent recurrence. Stress fractures are less likely to occur or recur when proper techniques for athletic training or work activity are followed. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was the diagnosis confirmed with x-rays, bone scan, or MRI?
  • If the diagnosis was uncertain, was the possibility of malignant femur tumor ruled out?
  • Did individual experience any complications that would prolong recovery?
  • Does individual have a pre-existing condition that may contribute to prolonged disability?

Regarding treatment:

  • Was the fracture treated promptly and appropriately?
  • Was surgery required? ORIF?
  • Was physical therapy prescribed?
  • Were other injuries sustained that required treatment? Was treatment given?

Regarding prognosis:

  • Considering the type of fracture, the presence of pre-existing conditions, age and general health of the individual, what is the expected outcome?
  • H individual continued to participate in physical therapy and rehabilitation exercises as directed?
  • Has adequate time elapsed for recovery?
  • Do other conditions (e.g., advanced age, decreased mental alertness, debilitating health problems, other injuries) impair individual's ability to participate in physical therapy?
  • Is pain interfering with rehabilitation? If so, have alternative pain relief interventions been tried?
  • Is individual motivated to adhere to prescribed physical therapy?
  • If lack of motivation is a barrier to recovery, have interventions been considered, such as adjustments to the rehabilitation prescription, changing the physical therapist, or seeking rehabilitation group therapy?
  • Has individual’s employer been able to address necessary accommodations and work restrictions?

Source: Medical Disability Advisor



References

Cited

Auron-Gomez, Moises, and Franklin Michota. "Medical Management of Hip Fracture." Clinics in Geriatric Medicine 24 4 (2008): 701-719. National Center for Biotechnology Information. National Library of Medicine. 13 Feb. 2009 <PMID: 18984382>.

Avenell, A., and HHG Handoll. "Nutritional supplementation for hip fracture aftercare in older people." Cochrane Database of Systematic Reviews. John. Wiley & Sons, 2006.

Bartels, E. "Aquatic Exercise for the Treatment of Knee and Hip Osteoarthritis." Cochrane Database of Systematic Reviews. Ed. E. Bartels. Issue 4 ed. John. Wiley & Sons, 2007. NA.

Cameron, I. D., et al. "Co-ordinated Multidisciplinary Approaches for Inpatient Rehabilitation of Older Patients with Proximal Femoral Fractures." Cochrane Database of Systematic Reviews 3 (2001): CD000106. National Center for Biotechnology Information. National Library of Medicine. 6 Jan. 2009 <PMID: 11686951>.

Handoll, H., C. Sherrington, and M. Parker. "Mobilisation Strategies after Hip Fracture Surgery in Adults." Cochrane Database of Systematic Reviews 4 (2004): CD001704. National Center for Biotechnology Information. National Library of Medicine. 6 Jan. 2009 <PMID: 15495015>.

Hegmann, Kurt T. , et al., eds. "Hip and Groin Disorders - Hip fracture (Activity Modification)." Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. Online ed. ACOEM, ACOEM Practice Guidelines Plus. American College of Occupational and Environmental Medicine. 28 Oct. 2010 <http://apg-i.acoem.org/Browser/TreatmentSummary.aspx?tsid=1149>.

Hegmann, Kurt T. , et al., eds. "Hip and Groin Disorders - Hip fracture (Medications)." Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. Online ed. ACOEM, ACOEM Practice Guidelines Plus. American College of Occupational and Environmental Medicine. 28 Oct. 2010 <http://apg-i.acoem.org/Browser/ViewRecommendation.aspx?rcm=1862&text=bisphosphonates>.

Khan, F. , et al. "Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy." Cochrane Database of Systematic Reviews. Eds. W. Laupattarakasem, et al. John. Wiley & Sons, 2008.

Koval, Kenneth K., and Joseph Zuckerman, eds. Fractures in the Elderly. Philadelphia: Lippincott-Raven Publishers, 1998.

LaVelle, David. "Chapter 52 - Fractures and Dislocations of the Hip." Campbell's Operative Orthopaedics. Eds. S. Terry Canale and James H. Beaty. 11th ed. Philadelphia: Mosby Elsevier, 2008.

Malanga, Gerard A., and Jennifer Solomon. "Femoral Neck Fracture." eMedicine. Eds. Janos P. Ertl, et al. 28 Jan. 2009. Medscape. 25 Oct. 2004 <http://emedicine.medscape.com/article/86659-overview>.

Oliver, David, et al., eds. "Hip Fracture." BMJ Clinical Evidence Handbook. BMJ Publishing Group, 2009. 370-372.

Source: Medical Disability Advisor