A 72-year-old woman from rural Maharashtra presents to the emergency department after a fall at home while walking to the kitchen. She reports severe pain in the right hip and groin. On examination, the right lower limb is held in external rotation and appears shortened compared to the left. Hip flexion and internal rotation are severely limited and painful. Plain radiographs confirm a fracture of the femoral neck. The fracture line is intracapsular and extends from the femoral head to the intertrochanteric region, with minimal displacement. Which of the following is the most appropriate initial management for this patient?

Explanation

## Initial Management of Intracapsular Femoral Neck Fracture **Key Point:** Intracapsular femoral neck fractures require urgent surgical intervention to prevent avascular necrosis (AVN) of the femoral head. The blood supply to the femoral head is retrograde and enters through the capsular attachment; displacement or delay in reduction compromises this tenuous supply. **High-Yield:** In a relatively undisplaced intracapsular femoral neck fracture (as described in this case), the gold standard is **immediate closed reduction and internal fixation with cannulated screws**. This approach: - Restores anatomical alignment quickly - Preserves the femoral head - Allows early mobilization and reduces complications (DVT, pneumonia, pressure ulcers) - Has a lower AVN rate compared to delayed fixation **Clinical Pearl:** The Garden classification (I–IV) guides management: - **Garden I–II (undisplaced):** CRIF with cannulated screws - **Garden III–IV (displaced):** In young patients, ORIF with screws; in elderly patients (>70 years), hemiarthroplasty is often preferred due to high AVN and nonunion rates with fixation alone This patient's fracture appears to be Garden I–II (minimal displacement), making cannulated screw fixation the most appropriate choice. **Mnemonic:** **RUSH** — **R**educe, **U**rgently, **S**crews, **H**ead-preserving (for undisplaced intracapsular NOF). ## Why Immediate Fixation? Delaying surgery (even by 24–48 hours) increases the risk of: 1. Further displacement 2. Avascular necrosis (AVN rate ~10–30% with delayed fixation vs. ~5–10% with immediate fixation) 3. Nonunion 4. Medical complications from prolonged immobility [cite:Rockwood & Green's Fractures in Adults 9e Ch 47]