Clin Orthop Surg.  2019 Mar;11(1):1-14. 10.4055/cios.2019.11.1.1.

Biomechanical Evaluation of Internal Fixation of Pauwels Type III Femoral Neck Fractures: A Systematic Review of Various Fixation Methods

  • 1Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea.
  • 2Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Jinju, Korea.


The purpose of this systematic review was to investigate various fixation methods or implants used in the treatment of Pauwels type III femoral neck fractures.
PubMed Central, OVID Medline, Cochrane Collaboration Library, Web of Science, Embase, and AHRQ databases were searched to identify relevant studies published until August 2017 with English language restriction. Studies were selected on the basis of the following inclusion criteria: biomechanical study of Pauwels type III femoral neck fractures and the use of dynamic hip screw (DHS) or multiple screw fixation or other devices for fixation of the fracture.
A total of 15 studies were included in the systematic review. Eight studies were conducted using cadavers, six studies using sawbones, and one using a finite element model. During the mechanical testing, each study measured mechanical stiffness, failure to cyclic loading, failure to vertical loading of each fixation device. DHS was included in 11 studies, multiple screw fixation in 10 studies, and other devices in six studies. Baitner et al. and Samsami et al. reported that the mechanical stiffness of DHS was superior to three inverted triangular screw fixation. Hawks et al. and Gumustas et al. reported that using a transverse calcar screw can withstand vertical loading better than three inverted triangular screw fixation. In addition, there were some studies where instruments such as Intertan nail, locking plate or other devices showed excellent biomechanical properties.
There are a variety of methods and instruments for fixation of the Pauwels type III fractures. However, it is difficult to conclude that any method is more desirable because there are advantages and disadvantages to each method. Therefore, we should pay attention to the implant choice and consider adequate weight bearing affecting the stiffness of the implant.


Hip; Femoral neck fractures; Treatment; Pauwels

MeSH Terms

Cooperative Behavior
Femoral Neck Fractures*
Femur Neck*


  • Fig. 1 Study flowchart. Fifteen studies were included for descriptive and qualitative analysis.


1. Swiontkowski MF. Intracapsular fractures of the hip. J Bone Joint Surg Am. 1994; 76(1):129–138. PMID: 8288657.
2. Der schenkelhalsbruch: Ein mechanisches Problem. By Dr. Friedrich Pauwels (Aachen). Royal 8vo. Pp. 157, with 186 illustrations. 1935. Stuttgart: Ferdinand Enke. Paper covers, RM. 13.60; bound, RM. 15.00. Br J Surg. 1936; 23(92):874.
3. Bartonicek J. Pauwels' classification of femoral neck fractures: correct interpretation of the original. J Orthop Trauma. 2001; 15(5):358–360. PMID: 11433141.
4. Hawks MA, Kim H, Strauss JE, et al. Does a trochanteric lag screw improve fixation of vertically oriented femoral neck fractures? A biomechanical analysis in cadaveric bone. Clin Biomech (Bristol, Avon). 2013; 28(8):886–891.
5. Ye Y, Hao J, Mauffrey C, Hammerberg EM, Stahel PF, Hak DJ. Optimizing stability in femoral neck fracture fixation. Orthopedics. 2015; 38(10):625–630. PMID: 26488776.
6. Gumustas SA, Tosun HB, Agir I, Orak MM, Onay T, Okcu G. Influence of number and orientation of screws on stability in the internal fixation of unstable femoral neck fractures. Acta Orthop Traumatol Turc. 2014; 48(6):673–678. PMID: 25637733.
7. Stoffel K, Zderic I, Gras F, et al. Biomechanical evaluation of the femoral neck system in unstable Pauwels III femoral neck fractures: a comparison with the dynamic hip screw and cannulated screws. J Orthop Trauma. 2017; 31(3):131–137. PMID: 27755333.
8. Noda M, Saegusa Y, Takahashi M, Tezuka D, Adachi K, Naoi K. Biomechanical study using the finite element method of internal fixation in Pauwels type III vertical femoral neck fractures. Arch Trauma Res. 2015; 4(3):e23167. PMID: 26566507.
9. Kuan FC, Yeh ML, Hong CK, et al. Augmentation by cerclage wire improves fixation of vertical shear femoral neck fractures: a biomechanical analysis. Injury. 2016; 47(10):2081–2086. PMID: 27461779.
10. Johnson JP, Borenstein TR, Waryasz GR, et al. Vertically oriented femoral neck fractures: a biomechanical comparison of 3 fixation constructs. J Orthop Trauma. 2017; 31(7):363–368. PMID: 28471920.
11. Samsami S, Saberi S, Sadighi S, Rouhi G. Comparison of three fixation methods for femoral neck fracture in young adults: experimental and numerical investigations. J Med Biol Eng. 2015; 35(5):566–579. PMID: 26500470.
12. Knobe M, Altgassen S, Maier KJ, et al. Screw-blade fixation systems in Pauwels three femoral neck fractures: a biomechanical evaluation. Int Orthop. 2018; 42(2):409–418. PMID: 28780597.
13. Marti RK, Schuller HM, Raaymakers EL. Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg Br. 1989; 71(5):782–787. PMID: 2584247.
14. Baitner AC, Maurer SG, Hickey DG, et al. Vertical shear fractures of the femoral neck: a biomechanical study. Clin Orthop Relat Res. 1999; (367):300–305. PMID: 10546628.
15. Windolf M, Braunstein V, Dutoit C, Schwieger K. Is a helical shaped implant a superior alternative to the Dynamic Hip Screw for unstable femoral neck fractures? A biomechanical investigation. Clin Biomech (Bristol, Avon). 2009; 24(1):59–64.
16. Rupprecht M, Grossterlinden L, Ruecker AH, et al. A comparative biomechanical analysis of fixation devices for unstable femoral neck fractures: the Intertan versus cannulated screws or a dynamic hip screw. J Trauma. 2011; 71(3):625–634. PMID: 21768904.
17. Rupprecht M, Grossterlinden L, Sellenschloh K, et al. Internal fixation of femoral neck fractures with posterior comminution: a biomechanical comparison of DHS® and Intertan nail®. Int Orthop. 2011; 35(11):1695–1701. PMID: 21286918.
18. Aminian A, Gao F, Fedoriw WW, Zhang LQ, Kalainov DM, Merk BR. Vertically oriented femoral neck fractures: mechanical analysis of four fixation techniques. J Orthop Trauma. 2007; 21(8):544–548. PMID: 17805021.
19. Nowotarski PJ, Ervin B, Weatherby B, Pettit J, Goulet R, Norris B. Biomechanical analysis of a novel femoral neck locking plate for treatment of vertical shear Pauwel's type C femoral neck fractures. Injury. 2012; 43(6):802–806. PMID: 22019259.
20. Kunapuli SC, Schramski MJ, Lee AS, et al. Biomechanical analysis of augmented plate fixation for the treatment of vertical shear femoral neck fractures. J Orthop Trauma. 2015; 29(3):144–150. PMID: 25072287.
21. Bergmann G, Deuretzbacher G, Heller M, et al. Hip contact forces and gait patterns from routine activities. J Biomech. 2001; 34(7):859–871. PMID: 11410170.
22. Meyers MH, Harvey JP Jr, Moore TM. The muscle pedicle bone graft in the treatment of displaced fractures of the femoral neck: indications, operative technique, and results. Orthop Clin North Am. 1974; 5(4):779–792. PMID: 4607207.
23. Tan V, Wong KL, Born CT, Harten R, DeLong WG Jr. Two-screw femoral neck fracture fixation: a biomechanical analysis of 2 different configurations. Am J Orthop (Belle Mead NJ). 2007; 36(9):481–485. PMID: 17948152.
24. Haidukewych GJ. Innovations in locking plate technology. J Am Acad Orthop Surg. 2004; 12(4):205–212. PMID: 15473672.
25. Kold S, Rahbek O, Vestermark M, Overgaard S, Soballe K. Bone compaction enhances fixation of weightbearing titanium implants. Clin Orthop Relat Res. 2005; (431):138–144.
26. Stulberg BN, Watson JT, Stulberg SD, Bauer TW, Manley MT. A new model to assess tibial fixation. II Concurrent histologic and biomechanical observations. Clin Orthop Relat Res. 1991; (263):303–309.
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