Moderate evidence supports operative fixation for patients with stable (non-displaced) femoral neck fractures.

Management of Hip Fractures in the Elderly
Endorsed by: OTA, AGS, AAPM&R, ASBMR, USBJI, The Hip Society, AACE, ORA
Moderate Evidence MODERATE EVIDENCE
Rationale
One high strength article compared operative to nonoperative treatment for non-displaced femoral neck fractures (Cserhati et al48). The major risk factor for non-operative treatment is displacement. It is unclear if this will lead to a more involved treatment such as arthroplasty with higher risks and if the risk- benefit curve favors this approach. There is unique difficulty in determining a truly non-displaced fracture and what patient will benefit from non-operative treatment. Operative treatment typically provides reproducible results with low risk, earlier mobilization and fewer complications.
 
Risks and Harms of Implementing this Recommendation
Higher morbidity, mortality, and longer hospital stays have been shown to be associated with non-operative treatment. The benefit of avoiding surgery and anesthesia was contrasted with a failure rate of approximately 20% in the non-operative treatment group that required surgery.
 
Future Research
Given high failure rates with non-operative treatment, clinical equipoise is lacking, making a study on non-operative treatment of hip fractures unethical. While there are clearly hip fracture patients with end of life issues who may be appropriate for non-operative treatment, surgical fixation may decrease pain, facilitate hygiene and nursing, and improve mobilization for end of life comfort. 
 
Special consideration for end of life issues, risks and limited benefits of surgery and the balancing of surgical goals with patient and family wishes.
 
 
  1. (48) Cserhati P, Kazar G, Manninger J, Fekete K, Frenyo S. Non-operative or operative treatment for undisplaced femoral neck fractures: a comparative study of 122 non-operative and 125 operatively treated cases. Injury 1996;27(8):583-588.