Femoral neck fracture Pauwels II: Definition, Uses, and Clinical Overview

Posted on February 27, 2026 | by drhip

Femoral neck fracture Pauwels II Introduction (What it is)

Femoral neck fracture Pauwels II is a way to classify a specific type of hip fracture.
It describes a femoral neck fracture with a “moderate” fracture angle linked to shear forces.
Clinicians most often use it when reading hip X-rays and discussing surgical planning.
It is a classification label, not a treatment by itself.

Why Femoral neck fracture Pauwels II used (Purpose / benefits)

A femoral neck fracture is a break in the “neck” of the femur (thigh bone) just below the femoral head (the ball of the hip joint). The Pauwels classification groups femoral neck fractures by the angle of the fracture line, because that angle affects the balance of forces acting at the break.

Femoral neck fracture Pauwels II is used to:

Describe biomechanics in plain terms: A more vertical fracture line tends to experience more “shear” (sliding) forces, while a more horizontal line tends to experience more “compression” (squeezing) forces.
Support consistent communication: It helps radiologists, orthopedic surgeons, physical therapists, and trainees talk about fracture patterns using the same language.
Guide treatment discussions: The classification can contribute to decision-making about fixation strategy (how hardware might hold the fracture), expected stability, and rehabilitation considerations.
Contextualize risk: Although outcomes vary by clinician and case, Pauwels category is often discussed alongside other factors (displacement, bone quality, blood supply concerns) that influence healing and complications.

Importantly, Pauwels classification is only one piece of the overall clinical picture. Most real-world decisions combine multiple classification systems and patient-specific details.

Indications (When orthopedic clinicians use it)

Orthopedic clinicians commonly use the Pauwels system (including Femoral neck fracture Pauwels II) in scenarios such as:

Reviewing hip X-rays (and sometimes CT or MRI) after a suspected femoral neck fracture
Documenting fracture morphology in clinic notes, operative reports, and radiology reads
Comparing fracture stability patterns during team handoffs or referrals
Planning internal fixation strategies (for example, considering how to counteract shear forces)
Teaching trainees how fracture angle affects biomechanics and healing environment
Discussing expected rehabilitation constraints in general terms (varies by clinician and case)

Contraindications / when it’s NOT ideal

Femoral neck fracture Pauwels II is a classification, so “contraindications” generally mean situations where this label is less useful, less reliable, or not applicable:

Fracture is not in the femoral neck (for example, intertrochanteric or subtrochanteric fractures), where other systems are typically used
Imaging does not clearly show the fracture line, such as poor-quality radiographs, challenging positioning, or overlapping anatomy
Nonstandard views or rotation make the fracture angle hard to estimate accurately
Complex or comminuted patterns (multiple fragments) where a single fracture-line angle may not capture stability
Pediatric hip fractures, which have different considerations (growth plates and different typical patterns)
Situations where displacement and vascular risk dominate decision-making, and other classifications (for example, displacement-based systems) may be emphasized more

In practice, clinicians often pair Pauwels with other descriptors rather than relying on it alone.

How it works (Mechanism / physiology)

Femoral neck fracture Pauwels II is based on biomechanics, not physiology in the way medications work. Its key principle is how the orientation of the fracture line changes the forces at the break during standing, walking, and muscle activation.

Biomechanical principle: shear vs compression

A more vertical fracture line tends to create higher shear forces, which can encourage the fracture surfaces to slide relative to one another.
A more horizontal fracture line tends to create higher compressive forces, which can press fracture surfaces together.

Pauwels II is commonly described as a moderate fracture angle (often cited in educational materials as roughly between Pauwels I and Pauwels III). Exact cutoffs can vary by reference and measurement technique, and clinical interpretation varies by clinician and case.

Relevant hip anatomy and tissues

Understanding this label is easier with a quick anatomy map:

Femoral head: the “ball” of the hip joint that fits into the acetabulum (socket).
Femoral neck: the narrow bridge of bone between the head and the shaft; this is the fracture location in question.
Capsule and retinacular vessels: tissues surrounding the hip that help support blood flow to the femoral head; femoral neck fractures can threaten that blood supply depending on the pattern and displacement.
Trabecular bone (inner spongy bone) and cortical bone (outer hard shell): bone quality influences fixation purchase and stability.
Hip abductors and other muscles: muscle pull contributes to force patterns across the femoral neck.

Onset, duration, reversibility (what applies here)

Because this is a classification, it does not have an onset or duration like a drug. What it does provide is a snapshot descriptor of fracture geometry at the time of imaging. The classification can change if repeat imaging reveals a different understanding of the fracture line, if displacement evolves, or if additional fracture components are identified.

Femoral neck fracture Pauwels II Procedure overview (How it’s applied)

Femoral neck fracture Pauwels II is not a procedure. It is a label applied during evaluation and planning. A typical workflow looks like this:

Evaluation / exam
– History (fall, twisting injury, sports injury, or atraumatic pain depending on context)
– Physical exam focused on hip pain, ability to bear weight, limb position, and neurovascular status (what clinicians assess, not a self-check)
Preparation (imaging and context)
– Hip and pelvis radiographs are commonly the starting point
– Additional imaging (CT or MRI) may be used when the fracture is subtle, complex, or not well seen on X-ray (varies by clinician and case)
– Clinicians document displacement, comminution, and patient factors (age, bone quality, functional status)
Intervention / testing (classification step)
– The clinician estimates the fracture line angle and assigns a Pauwels category, such as Femoral neck fracture Pauwels II
– This is typically combined with other classification language (for example, displacement-based descriptors)
Immediate checks (clinical implications)
– The team considers stability, likelihood of maintaining alignment, and risks that influence treatment selection
– Discussions may include whether internal fixation or arthroplasty is being considered, but the classification alone does not determine the choice
Follow-up (reassessment over time)
– Repeat imaging is often used to assess alignment and healing progression after treatment, with the understanding that management plans vary widely by case

Types / variations

There are two main ways “types” come up with Femoral neck fracture Pauwels II: variations of the fracture pattern and variations of how classification is used.

Variations within femoral neck fractures (commonly described)

Nondisplaced vs displaced: Displacement refers to whether the bone ends have shifted. This is often a major driver of management discussions.
Subcapital, transcervical, basicervical location: These describe where along the neck the fracture sits, which can affect stability and fixation choices.
Simple vs comminuted: A simple fracture has a cleaner line; comminution means multiple fragments.
Associated injury patterns: Some injuries involve additional hip or pelvic trauma, changing priorities and surgical planning.

Variations in classification approach

Pauwels angle estimation can be influenced by patient positioning, X-ray projection, and the observer’s measurement method.
Many clinicians use Pauwels alongside Garden classification (commonly used for displacement) and/or AO/OTA systems for broader categorization.
The term “Pauwels II” may be used more as a conceptual stability marker than a rigid numeric measurement in everyday clinical communication.

Pros and cons

Pros:

Helps describe femoral neck fracture stability in terms of shear vs compression forces
Provides a shared language for clinicians across orthopedics, radiology, and rehab
Useful for teaching biomechanics and why fracture orientation matters
Can support treatment planning discussions (for example, fixation strategy considerations)
Simple framework that is easy to remember and apply in routine documentation

Cons:

Measurement can be inconsistent due to X-ray angle, rotation, and observer technique
Does not directly capture displacement, which is often clinically central
Does not include patient-specific factors like bone quality or comorbidities that influence outcomes
Complex or comminuted fractures may not fit neatly into a single angle-based category
Alone, it may oversimplify the risk profile; most decisions rely on multiple inputs

Aftercare & longevity

Because Femoral neck fracture Pauwels II is a classification rather than a treatment, “aftercare” relates to what typically influences recovery and durability of results after a femoral neck fracture has been managed (nonoperative or operative, depending on the case).

Key factors that commonly affect outcomes and longevity include:

Severity and displacement of the fracture: More displacement generally implies greater instability and different risk considerations.
Time course and follow-up schedule: Monitoring plans and imaging intervals vary by clinician and case.
Weight-bearing status: Restrictions (or progression) depend on fracture stability and the chosen treatment; protocols vary widely.
Rehabilitation participation: Physical therapy goals often include restoring gait mechanics, hip strength, balance, and functional mobility, but the pace and milestones vary.
Bone health and bone quality: Osteoporosis, nutrition status, and other bone-metabolism factors can influence healing potential.
Smoking status and systemic health: Vascular health, diabetes, and other comorbidities can affect recovery in general terms.
Implant or procedure choice (when surgery is used): Outcomes can be influenced by construct design and technique; specifics vary by material and manufacturer and by surgeon preference.
Complication surveillance: Clinicians often watch for alignment changes, fixation failure, nonunion, and femoral head blood supply problems, depending on the pattern and displacement.

In everyday terms, the “longevity” question is less about the Pauwels II label itself and more about whether the fracture heals in good alignment, whether hip function returns, and whether complications develop over time.

Alternatives / comparisons

Femoral neck fracture Pauwels II is one way to classify a femoral neck fracture, but it is not the only framework used. Common comparisons include:

Pauwels vs Garden classification
Pauwels emphasizes fracture angle and shear forces.
Garden is commonly used to describe displacement patterns of femoral neck fractures.
In practice, clinicians often document both, because they answer different questions.
Pauwels vs AO/OTA systems
AO/OTA classification aims for broad standardization across many fracture types.
Pauwels is narrower and focuses on a biomechanical feature particularly relevant to femoral neck fractures.
Classification vs imaging choice (X-ray, CT, MRI)
X-rays are commonly the first-line tool, but subtle fractures may not be obvious early on.
CT can better define complex bony anatomy.
MRI can detect occult fractures and assess surrounding tissue, and is often discussed when X-rays are negative but suspicion remains (use varies by case).
Classification vs treatment pathways (nonoperative monitoring, internal fixation, arthroplasty)
Pauwels category may inform stability considerations, but treatment selection typically depends on displacement, patient age/physiology, bone quality, and functional needs.
The same Pauwels II label may lead to different approaches in different patients, reflecting clinical nuance.

Femoral neck fracture Pauwels II Common questions (FAQ)

Q: What does Femoral neck fracture Pauwels II mean in simple terms?
It means the fracture line in the femoral neck is angled in a way that creates a moderate amount of sliding (shear) force across the break. Clinicians use it to describe stability and to communicate about the fracture pattern. It does not, by itself, tell you the exact treatment or outcome.

Q: Is Pauwels II considered “stable” or “unstable”?
Pauwels II is often viewed as intermediate on a stability spectrum, with more shear than low-angle fractures and less shear than very vertical fractures. Stability in real life also depends heavily on whether the fracture is displaced and on bone quality. Interpretation varies by clinician and case.

Q: Does the Pauwels classification predict whether the fracture will heal?
It can contribute to the discussion because fracture angle influences biomechanics, which can affect how well the fracture surfaces stay compressed together. However, healing depends on many factors beyond angle, including displacement, blood supply to the femoral head, overall health, and treatment method. No single classification fully predicts outcomes.

Q: How is the Pauwels type determined—do I need a special scan?
It is most commonly estimated from standard hip X-rays. Sometimes CT or MRI is used when the fracture line is hard to see or when a more detailed view is needed. Which imaging is used depends on the clinical scenario.

Q: Does a Pauwels II fracture always require surgery?
Not always. The decision depends on factors such as displacement, patient health, functional needs, and clinician judgment. The Pauwels label is one part of the overall assessment rather than a standalone rule.

Q: How painful is a femoral neck fracture, and does the Pauwels type change pain level?
Femoral neck fractures are commonly painful, especially with movement or attempts to bear weight. The Pauwels type describes fracture geometry and forces, not a direct measure of pain. Pain experience varies widely among individuals and clinical contexts.

Q: How long does recovery take for a femoral neck fracture labeled Pauwels II?
Recovery timelines vary by case and depend on treatment approach, displacement, complications, and rehabilitation progress. Some people regain function gradually over weeks to months, while others require longer. Your care team typically frames expectations around the specific fracture and management plan.

Q: Will I be allowed to put weight on the leg after treatment?
Weight-bearing recommendations depend on fracture stability and the treatment method used. Some protocols restrict weight initially, while others progress sooner, and these plans can differ across clinicians and institutions. It’s a common topic during follow-up because it influences healing and function.

Q: When can someone drive or return to work after a femoral neck fracture?
Return to driving or work depends on pain control, mobility, reaction time, side of injury, medications, and job demands, as well as the treating clinician’s restrictions. Desk work and physically demanding jobs often differ in timeline. This is typically individualized rather than determined by the Pauwels category alone.

Q: What does treatment cost for a femoral neck fracture, and does Pauwels II affect cost?
Costs vary widely by region, facility, insurance coverage, imaging needs, and whether surgery and hospitalization are required. The Pauwels label itself does not set the cost, but it may be part of the documentation that describes fracture complexity. For accurate estimates, patients usually need facility- and plan-specific billing information.