A 72-year-old woman presents to the emergency department after a fall at home while getting out of bed. She reports severe pain in the right hip and is unable to bear weight. On examination, the right lower limb is held in flexion, adduction, and internal rotation. X-ray of the pelvis shows a fracture through the femoral neck with the fracture line extending from the superior aspect of the femoral neck to the inferior aspect, with minimal displacement. What is the most appropriate initial management for this fracture?

Explanation

## Diagnosis and Classification **Key Point:** This is an undisplaced (or minimally displaced) femoral neck fracture, classified as a Garden Grade I–II fracture based on the description of minimal displacement and the fracture line orientation. ## Management Algorithm for Femoral Neck Fractures ```mermaid flowchart TD A[Femoral Neck Fracture]:::outcome --> B{Displacement?}:::decision B -->|Undisplaced/Minimal| C{Age and Comorbidities?}:::decision B -->|Displaced| D{Age?}:::decision C -->|Young/Fit| E[Internal Fixation: Cannulated Screws]:::action C -->|Elderly/Unfit| F[Consider THA if high demand]:::action D -->|<60 years| G[Internal Fixation: Cannulated Screws]:::action D -->|>60 years| H[Total Hip Arthroplasty]:::action E --> I[Preserve femoral head]:::outcome G --> I H --> J[Replace with prosthesis]:::outcome ``` ## Rationale for Cannulated Screws **High-Yield:** Undisplaced femoral neck fractures in patients who are medically fit (regardless of age in this case, as the patient is ambulatory) are best managed with **internal fixation using 3 cannulated screws** placed percutaneously under fluoroscopic guidance. **Clinical Pearl:** The blood supply to the femoral head is precarious and originates from the medial and lateral femoral circumflex arteries, which run along the femoral neck. Undisplaced fractures have a better chance of maintaining this blood supply if fixed early, reducing the risk of avascular necrosis (AVN). **Key Point:** Percutaneous cannulated screw fixation: - Preserves the femoral head and hip joint - Allows early mobilization and weight bearing (partial to full, depending on fracture stability) - Has a high union rate (>90%) in undisplaced fractures - Minimally invasive approach reduces operative morbidity ## Why Other Options Are Suboptimal | Option | Why Not Preferred | |--------|-------------------| | Bed rest with traction | Outdated approach; increases risk of DVT, pneumonia, pressure ulcers; prolonged immobility in elderly is harmful | | Total hip arthroplasty | Indicated for displaced fractures in elderly (>60 years) or young patients with high functional demand; not first-line for undisplaced fractures | | Conservative management alone | High risk of nonunion and malunion; loss of hip function; patient is fit enough for surgery | [cite:Rockwood & Green's Fractures in Adults Ch 48]