A 68-year-old man from Delhi presents with acute onset severe pain in the right hip and groin after a fall from standing height. He is unable to bear weight and the right lower limb is held in flexion, adduction, and internal rotation. X-ray confirms a displaced intracapsular femoral neck fracture. What is the most appropriate next step in management?

Explanation

## Management of Displaced Intracapsular Femoral Neck Fracture ### Clinical Context This patient has a displaced intracapsular (subcapital) femoral neck fracture — a surgical emergency due to high risk of avascular necrosis (AVN) of the femoral head. **Key Point:** Displaced intracapsular femoral neck fractures require urgent surgical fixation within 6–12 hours to minimize AVN risk. The blood supply to the femoral head is precarious and is further compromised by fracture displacement and intracapsular hematoma. ### Why Immediate Fixation? 1. **Vascular compromise:** The medial and lateral femoral circumflex arteries (branches of profunda femoris) supply the femoral head. Displacement disrupts these vessels and increases intracapsular pressure, leading to ischemia. 2. **Time-sensitive:** AVN risk increases exponentially with delay beyond 12 hours. 3. **Fracture pattern:** Displaced intracapsular fractures (Garden III–IV) have union rates <50% without surgery and AVN rates >50% if managed conservatively. ### Surgical Technique - **Cannulated screws (3 screws in inverted triangle)** are the gold standard for displaced intracapsular fractures in younger patients (<60 years) and selected older patients with good bone quality. - Provides rigid fixation, allows early mobilization, and preserves the femoral head. - In very elderly or medically unfit patients, hemiarthroplasty may be considered, but this patient is a candidate for fixation. **High-Yield:** Intracapsular fractures are classified by Garden's classification: - **Garden I–II (undisplaced):** Internal fixation with screws - **Garden III–IV (displaced):** Urgent internal fixation (if age <60) or hemiarthroplasty (if age >60 with poor bone quality) ### Why NOT the Other Options? - **Traction first:** Delays definitive fixation and increases AVN risk; traction is not indicated. - **Conservative management:** Leads to non-union and AVN; no role in displaced fractures. - **Arthrography:** Diagnostic, not therapeutic; wastes critical time. **Clinical Pearl:** The "golden period" for intracapsular femoral neck fracture fixation is within 6–12 hours of injury. Delays beyond this significantly increase morbidity. [cite:Rockwood & Green's Fractures in Adults Ch 53]