A 65-year-old man sustains a fall from standing height and presents with left hip pain and inability to walk. Radiographs reveal a fracture of the femoral neck. On careful examination, the fracture line is below the insertion of the capsule, and there is minimal displacement. The fracture is classified as Garden Grade II. What is the most appropriate initial management?

Explanation

## Management of Undisplaced Intracapsular Femoral Neck Fracture (Garden Grade II) ### Fracture Classification and Blood Supply **Key Point:** Garden Grade II fractures are **minimally displaced or impacted** intracapsular fractures. The critical distinction is that the blood supply to the femoral head is largely **preserved** because the fracture does not significantly disrupt the medial femoral circumflex artery. ### Why Cannulated Screws Are Indicated 1. **Preserved vascularity** — Minimal displacement means the femoral head retains adequate blood supply; union is likely without AVN. 2. **High union rates** — Reported union rates exceed 90% in undisplaced/minimally displaced fractures with appropriate fixation. 3. **Maintains native hip** — Preserves the patient's own joint, avoiding prosthesis-related complications (wear, loosening, revision). 4. **Early mobilization** — Rigid fixation allows early weight-bearing and physiotherapy. 5. **Age-appropriate** — In a 65-year-old, preserving the native hip is preferable to prosthetic replacement. ### Intracapsular vs. Extracapsular Fractures: Blood Supply | Feature | Intracapsular (Femoral Neck) | Extracapsular (Intertrochanteric/Subtrochanteric) | | --- | --- | --- | | **Blood supply** | Medial femoral circumflex artery (at risk if displaced) | Lateral femoral circumflex artery (usually preserved) | | **AVN risk** | High if displaced; low if undisplaced | Very low | | **Union rate** | Depends on displacement; poor if displaced | Excellent (>95%) | | **Management (undisplaced)** | CRIF with cannulated screws | CRIF with DHS or intramedullary nail | | **Management (displaced, elderly)** | Hemiarthroplasty | CRIF (DHS/nail) | ### Garden Classification and Management Algorithm ```mermaid flowchart TD A[Intracapsular femoral neck fracture]:::outcome --> B{Garden grade?}:::decision B -->|Grade I: Incomplete/valgus impacted| C[CRIF with cannulated screws]:::action B -->|Grade II: Complete, non-displaced| D[CRIF with cannulated screws]:::action B -->|Grade III: Complete, partially displaced| E{Patient age?}:::decision B -->|Grade IV: Complete, fully displaced| F{Patient age?}:::decision E -->|Young <60 yrs| G[CRIF with cannulated screws]:::action E -->|Elderly >65 yrs| H[Hemiarthroplasty]:::action F -->|Young <60 yrs| I[CRIF with cannulated screws]:::action F -->|Elderly >65 yrs| J[Hemiarthroplasty]:::action C --> K[High union rate, low AVN risk]:::outcome D --> K G --> L[Attempt union preservation]:::outcome H --> M[Early mobilization, accept AVN risk]:::outcome ``` **High-Yield:** Garden Grade I–II fractures have **preserved blood supply** and should be treated with **CRIF using cannulated screws**, regardless of age, because union rates are excellent (>90%) and AVN risk is low (<5%). ### Technique: Cannulated Screws - **Number:** Minimum 2–3 screws for stability. - **Placement:** Parallel or divergent configuration; avoid crossing the fracture line perpendicularly (risk of malunion). - **Reduction:** Closed reduction under fluoroscopy; open reduction only if closed reduction fails. - **Weight-bearing:** Typically non-weight-bearing for 6–8 weeks, then progressive weight-bearing as union progresses. **Clinical Pearl:** The key to successful CRIF in undisplaced fractures is **early diagnosis and prompt fixation** (within 24–48 hours) to prevent secondary displacement and AVN.