A 72-year-old woman presents to the emergency department following a fall at home while walking to the bathroom at night. She reports severe pain in the left hip and is unable to bear weight. On examination, the left lower limb is held in external rotation and appears shortened compared to the right. Plain radiographs confirm a displaced intracapsular fracture of the left femoral neck. Her past medical history includes hypertension and type 2 diabetes. What is the most appropriate initial management for this patient?

Explanation

## Management of Displaced Intracapsular Femoral Neck Fracture ### Clinical Context This patient has a **displaced intracapsular (subcapital) fracture of the femoral neck**, which is a surgical emergency due to the high risk of avascular necrosis (AVN) of the femoral head. ### Why Urgent ORIF with Cannulated Screws? **Key Point:** Displaced intracapsular femoral neck fractures require urgent surgical fixation within 6–12 hours to minimize the risk of AVN. The femoral head has a precarious blood supply that is easily disrupted by displacement and time delay. **High-Yield:** In displaced intracapsular fractures (Garden III–IV), the blood supply to the femoral head is already compromised. Every hour of delay increases the risk of AVN from ~10% (immediate fixation) to >50% (delayed fixation >24 hours). **Clinical Pearl:** Cannulated screws (typically 3 screws in an inverted triangle) are the standard fixation method for intracapsular femoral neck fractures in younger patients (<60 years) and selected older patients with good bone quality. This allows early mobilization and preserves the femoral head. ### Why Other Options Are Incorrect | Management | Indication | Why Not Here | |---|---|---| | **Skeletal traction** | Undisplaced/stress fractures | Delays definitive fixation; increases AVN risk in displaced fractures | | **Conservative care** | Non-operative candidates (bed-bound, terminal illness) | This patient is ambulatory and can tolerate surgery | | **Hemiarthroplasty** | Displaced fractures in elderly (>65 yrs) with poor bone quality | May be considered in this age group, but ORIF is still preferred if fixation is technically feasible | **Mnemonic: DISPLACED INTRACAPSULAR = URGENT ORIF** — Do not delay; every hour counts for blood supply preservation. ### Timing is Critical ```mermaid flowchart TD A[Displaced Intracapsular NOF Fracture]:::outcome --> B{Time since injury?}:::decision B -->|< 6 hours| C[Urgent ORIF with cannulated screws]:::action B -->|6-12 hours| C B -->|> 12 hours| D{Age & bone quality?}:::decision D -->|Elderly/poor bone| E[Hemiarthroplasty]:::action D -->|Young/good bone| F[ORIF still attempted]:::action C --> G[Early mobilization]:::action E --> H[Lower AVN risk]:::outcome F --> I{Fixation successful?}:::decision I -->|Yes| J[Preserve femoral head]:::outcome I -->|No| K[Consider conversion to arthroplasty]:::urgent ``` [cite:Rockwood & Green's Fractures in Adults Ch 53]