A 72-year-old woman from Delhi presents to the emergency department after a fall at home while getting out of bed. She reports severe pain in the left hip and is unable to bear weight. On examination, the left lower limb is held in external rotation and appears shortened compared to the right. Plain radiographs confirm a fracture of the femoral neck. The fracture line is located between the femoral head and the intertrochanteric region, with minimal displacement. What is the most appropriate initial management for this fracture?

Explanation

## Classification and Management of Femoral Neck Fractures ### Fracture Type Assessment **Key Point:** The vignette describes a minimally displaced femoral neck fracture in an elderly patient — a common presentation in NEET PG orthopedics. The fracture is: - **Location:** Between femoral head and intertrochanteric region (femoral neck proper) - **Displacement:** Minimal (Garden Grade I–II) - **Patient:** Elderly, likely independent prior to injury ### Management Algorithm ```mermaid flowchart TD A[Femoral Neck Fracture]:::outcome --> B{Displacement?}:::decision B -->|Minimal/None<br/>Garden I-II| C{Patient age<br/>& fitness?}:::decision B -->|Moderate-Severe<br/>Garden III-IV| D[ORIF or Arthroplasty]:::action C -->|Young,<br/>fit| E[ORIF with<br/>cannulated screws]:::action C -->|Elderly,<br/>unfit| F[Hemiarthroplasty]:::action E --> G[Preserve femoral head]:::outcome F --> H[Replace femoral head]:::outcome ``` ### Why Cannulated Screws? 1. **Minimally displaced fractures** (Garden I–II) have excellent healing potential if anatomically reduced and held stable. 2. **Cannulated screws** (typically 3 screws in an inverted triangle) allow: - Percutaneous or mini-open insertion - Preservation of femoral head blood supply - Early mobilization - Lower infection risk than open reduction 3. **Success rate:** 80–90% union in non-displaced fractures with proper fixation. ### Why NOT the Other Options? - **Skeletal traction (Option B):** Outdated. Prolonged immobility in elderly patients causes pressure sores, DVT, pneumonia, and deconditioning. No longer standard of care. - **Conservative management (Option C):** Non-union and avascular necrosis are inevitable without fixation. Bed rest alone is harmful in the elderly. - **Hemiarthroplasty (Option D):** Reserved for **displaced fractures** (Garden III–IV) or pathological fractures in patients unfit for ORIF. This fracture is minimally displaced and the patient is fit for surgery. ### High-Yield Pearls **High-Yield:** Garden classification guides management: - **Garden I–II (non/minimally displaced):** ORIF with cannulated screws - **Garden III–IV (displaced):** ORIF in young patients; hemiarthroplasty in elderly/unfit **Clinical Pearl:** Femoral neck fractures carry risk of avascular necrosis (AVN) due to retrograde blood supply. Early anatomic reduction and stable fixation minimize this risk. **Mnemonic:** **ORIF for Non-displaced, Arthroplasty for Displaced** — remember the fracture pattern, not just the patient age.