A 72-year-old woman presents to the emergency department following a fall at home while getting out of bed. She complains of severe pain in the left hip and is unable to bear weight. On examination, the left lower limb is held in flexion, adduction, and internal rotation. Hip movements are restricted and painful. Plain radiographs confirm a displaced intracapsular fracture of the femoral neck. What is the most appropriate management for this patient?

Explanation

## Management of Displaced Intracapsular Femoral Neck Fracture ### Classification Context Intracapsular femoral neck fractures are classified by displacement (Garden classification). Displaced fractures (Garden III–IV) in elderly patients carry a high risk of avascular necrosis (AVN) due to disruption of the medial femoral circumflex artery, which supplies the femoral head. ### Why Hemiarthroplasty is Preferred **Key Point:** In elderly patients (typically >60–70 years) with displaced intracapsular femoral neck fractures, hemiarthroplasty is the gold standard because: 1. **High AVN risk** — Displaced fractures compromise the blood supply to the femoral head; union rates are poor and AVN rates exceed 30–40%. 2. **Avoids prolonged immobility** — Early mobilization reduces pneumonia, thromboembolism, and pressure ulcers. 3. **Functional outcome** — Hemiarthroplasty allows rapid weight-bearing and return to baseline function. 4. **Prosthesis choice** — Austin Moore (unipolar) or bipolar prostheses are used; bipolar is preferred in younger, more active patients to reduce acetabular wear. ### Comparison of Options | Management | Indication | Outcome | Drawback | | --- | --- | --- | --- | | **Cannulated screws** | Undisplaced or minimally displaced (Garden I–II) fractures; young patients | Good union rates if blood supply intact | High AVN risk in displaced fractures; prolonged bed rest | | **Hemiarthroplasty** | Displaced fractures (Garden III–IV) in elderly (>65–70 yr) | Early mobilization, good functional outcome | Acetabular wear (especially unipolar); revision risk | | **Total hip arthroplasty** | Displaced fractures with pre-existing hip OA or very active elderly | Best long-term outcome | Higher operative time, blood loss, cost; not routine in acute fracture | | **Conservative management** | Medically unfit, very short life expectancy | Avoids surgery | High mortality (20–30% at 1 year), pressure ulcers, DVT/PE | **Clinical Pearl:** The 10-year mortality after femoral neck fracture in elderly patients is ~50%; early mobilization via surgical fixation is critical to reduce mortality and morbidity. ### Age-Based Decision Algorithm ```mermaid flowchart TD A[Intracapsular femoral neck fracture]:::outcome --> B{Displacement?}:::decision B -->|Undisplaced/minimally displaced| C[Garden I-II]:::outcome B -->|Displaced| D[Garden III-IV]:::outcome C --> E{Patient age & fitness?}:::decision D --> F{Patient age & fitness?}:::decision E -->|Young, fit| G[CRIF with cannulated screws]:::action E -->|Elderly, unfit| H[Conservative or CRIF]:::action F -->|Young, fit| I[CRIF with cannulated screws]:::action F -->|Elderly >65-70 yrs| J[Hemiarthroplasty]:::action F -->|Very active, pre-existing OA| K[Total hip arthroplasty]:::action J --> L[Early mobilization, good functional outcome]:::outcome K --> M[Best long-term outcome]:::outcome ``` **High-Yield:** In this 72-year-old with a displaced intracapsular fracture, hemiarthroplasty is the standard of care because it allows immediate weight-bearing and mobilization, reducing mortality and morbidity.