A 68-year-old man from Delhi presents with severe right hip pain and inability to bear weight after a fall from a standing height 3 days ago. He was initially managed conservatively at a primary health center with analgesics and bed rest. On examination, the right lower limb is held in flexion, adduction, and internal rotation. Radiographs show a displaced intracapsular femoral neck fracture (Garden IV). The patient is medically fit with no significant comorbidities. What is the most appropriate surgical management for this patient?

Explanation

## Management of Displaced Intracapsular Femoral Neck Fracture **Key Point:** Displaced intracapsular femoral neck fractures (Garden III–IV) carry a high risk of avascular necrosis (AVN) and nonunion when treated with internal fixation alone. In elderly patients (typically >65 years), **primary hemiarthroplasty** is the standard of care to avoid these complications and restore early mobility. **High-Yield:** The Garden classification guides surgical strategy: | Garden Grade | Displacement | Patient Age | Recommended Treatment | |---|---|---|---| | I–II | Undisplaced | Any | CRIF with cannulated screws | | III–IV | Displaced | <60 years | ORIF with screws (preserve head) | | III–IV | Displaced | 60–65 years | Individualize: ORIF vs. hemiarthroplasty | | III–IV | Displaced | >65 years | Hemiarthroplasty (preferred) | This 68-year-old patient has a **Garden IV (fully displaced) fracture**. His age places him firmly in the hemiarthroplasty category. **Primary hemiarthroplasty** is preferred because: 1. **AVN risk:** Displacement disrupts the retrograde blood supply to the femoral head; AVN rates with fixation alone approach 30–50% 2. **Nonunion risk:** Displaced fractures have high nonunion rates (20–30%) even with optimal fixation 3. **Early mobilization:** Hemiarthroplasty allows immediate weight-bearing and physiotherapy, reducing immobility-related complications 4. **Functional outcome:** Patients achieve reliable pain relief and hip function with arthroplasty **Why not THA?** Total hip arthroplasty (THA) is generally reserved for patients with pre-existing acetabular disease (e.g., osteoarthritis), higher functional demand (younger-elderly, very active patients), or rheumatoid arthritis. For a straightforward displaced femoral neck fracture in a 68-year-old without acetabular pathology, hemiarthroplasty remains the standard first-line surgical option per Campbell's Operative Orthopaedics and most national guidelines. THA may offer marginally better long-term functional scores in highly active patients, but carries higher dislocation risk and operative complexity. **Clinical Pearl:** **Bipolar vs. unipolar hemiarthroplasty** — both are acceptable options. Bipolar prostheses theoretically reduce acetabular erosion and facilitate later conversion to THA; however, post-2015 evidence (including the HEALTH trial meta-analyses) shows comparable functional outcomes between the two in elderly patients. In resource-limited settings, unipolar prostheses are cost-effective and widely used. The choice should be individualized based on patient activity level, institutional resources, and surgeon preference. **Why not delayed ORIF or conservative management?** Delayed fixation (>48–72 hours) increases AVN risk and is not recommended for displaced fractures in the elderly. Conservative management is inappropriate for displaced fractures due to high rates of malunion, nonunion, and prolonged immobility complications. **Mnemonic:** **DISH** — **D**isplaced, **I**ntracapsular, **S**enior (>65), **H**emiarthroplasty. ## Timing Surgery should be performed urgently (within 24–48 hours of presentation) to minimize immobility-related complications and optimize outcomes. [cite: Campbell's Operative Orthopaedics 13e Ch 56; Rockwood & Green's Fractures in Adults 9e Ch 47; NICE Guideline NG111 – Hip Fracture Management]