## Garden Classification of Femoral Neck Fractures **Key Point:** The Garden classification is the most widely used system for grading intracapsular femoral neck fractures based on the degree of displacement and continuity of the fracture line. ### Garden Classification System | Grade | Description | Displacement | Prognosis | AVN Risk | |-------|-------------|--------------|-----------|----------| | I | Incomplete (stress fracture) | None | Excellent | <5% | | II | Complete, no displacement | None | Good | 10–15% | | III | Complete, partial displacement | Partial (femoral head partially rotated) | Fair | 20–30% | | IV | Complete, complete displacement | Full (femoral head completely rotated) | Poor | 30–40% | ### Grade III Characteristics **High-Yield:** Grade III fractures are the most clinically challenging because: 1. **Partial displacement** — The fracture line is complete through the femoral neck, but the femoral head maintains partial contact with the femoral neck fragment. 2. **Femoral head rotation** — The proximal fragment (femoral head) is partially rotated relative to the distal fragment (femoral neck), typically by 45–90 degrees. 3. **Vascular compromise** — The medial femoral circumflex artery is partially stretched, resulting in moderate vascular disruption and intermediate AVN risk (20–30%). **Clinical Pearl:** Grade III fractures occupy a "gray zone" in management: - In younger patients (< 60 years), internal fixation with multiple cannulated screws is preferred to preserve femoral head viability. - In elderly patients, the decision between fixation and hemiarthroplasty depends on bone quality and comorbidities. **Mnemonic:** **Garden I–II = Stable (non-displaced); Garden III–IV = Unstable (displaced)** — Grades I–II have good prognosis with conservative or minimal fixation; Grades III–IV require aggressive fixation or replacement. 
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