Once a radiological diagnosis has been made, a decision about nonoperative management can be taken.
For nonimpacted intracapsular fractures, the best nonsurgical care is to relieve pain and mobilize the patient despite the fracture. These fractures will usually not unite with nonsurgical treatment, and mobilization of the patient as a whole will minimize systemic complications.
If a radiological diagnosis is not available, the possibility of a displaced intracapsular fracture of the proximal femur may be suggested by external rotation with slight to moderate shortening (2.5–5 cm), which increases only slightly with proximally directed pressure on the leg. Nonoperative treatment of such patients is not based upon bone healing, which, as noted, does not occur without surgical treatment. Traction can be omitted or discontinued, and the patient should be mobilized as soon as comfort permits.
If there is marked thigh shortening that increases progressively or is associated with palpable bone deformity, the patient is more likely to have an extracapsular fracture with much higher healing potential. Patients with these injuries are reasonable candidates for 6 weeks of traction, as described below, followed by mobilization out of bed to avoid excessive deformity.
For proximal femur fractures that are likely to be extracapsular (intertrochanteric or pertrochanteric), the nonoperative regimen is as follows.