A 72-year-old woman with osteoporosis presents to the emergency department 6 hours after a fall at home with severe pain in the left hip and inability to bear weight. On examination, the left leg is externally rotated and shortened. X-ray confirms a displaced intracapsular neck of femur fracture. She is medically fit for surgery. What is the most appropriate next step in management?

Explanation

## Management of Displaced Intracapsular Neck of Femur Fracture ### Classification Context Intracapsular neck of femur fractures are classified by Garden's classification (I–IV). Displaced fractures (Garden III–IV) in elderly, medically fit patients require urgent surgical intervention — arthroplasty is the treatment of choice. ### Why Total Hip Arthroplasty (THA)? **Key Point:** In a medically fit, active elderly patient (age 60–80 years) with a displaced intracapsular neck of femur fracture, **total hip arthroplasty (THA)** is the preferred surgical option. It offers superior functional outcomes, lower rates of reoperation, and avoids the high risk of avascular necrosis (AVN) and non-union associated with internal fixation in this age group. **High-Yield:** The landmark HEALTH trial (NEJM, 2019) demonstrated that THA results in significantly better functional outcomes compared to internal fixation in patients ≥50 years with displaced femoral neck fractures who are fit for surgery. Hemiarthroplasty is an alternative for less active or older patients (>80 years), but THA is preferred for active, medically fit patients aged 60–80 years. ### Surgical Options by Age and Fracture Type | Factor | Undisplaced (Garden I–II) | Displaced (Garden III–IV) | |--------|---------------------------|---------------------------| | **Age < 60 years** | CRIF (cannulated screws) | CRIF (attempt to preserve femoral head) | | **Age 60–80 years (fit, active)** | CRIF | **THA (preferred)** or Hemiarthroplasty | | **Age > 80 years / less active** | CRIF | Hemiarthroplasty | | **Medically unfit** | Conservative / CRIF | Hemiarthroplasty | ### In This Case - **Patient age:** 72 years (active age group) - **Fracture type:** Displaced intracapsular (Garden III–IV) - **Medical fitness:** Good (fit for surgery) - **Osteoporosis:** Present (increases AVN and fixation failure risk) - **Recommendation:** **Urgent Total Hip Arthroplasty (THA)** — best functional outcome, lowest reoperation rate **Clinical Pearl:** Internal fixation with cannulated screws in a 72-year-old with a displaced intracapsular fracture carries a 20–40% risk of AVN and up to 30% reoperation rate. Arthroplasty eliminates this risk and allows immediate weight-bearing and early mobilization. ### Why Not Other Options? - **Internal fixation with cannulated screws (Option A):** Appropriate only in patients <60 years where femoral head preservation is paramount. In a 72-year-old with osteoporosis and a displaced fracture, the high AVN and non-union risk makes this suboptimal. - **Skeletal traction and delayed surgery (Option B):** Outdated; delays definitive treatment, increases complications (DVT, pneumonia, pressure ulcers), and worsens outcomes. - **Conservative management (Option C):** Unacceptable in a medically fit patient; associated with very high morbidity and mortality in elderly patients. [cite: HEALTH Trial, NEJM 2019; Campbell's Operative Orthopaedics Ch 56; Rockwood & Green's Fractures in Adults, 9th Ed]