An 82-year-old man from Delhi presents to the orthopedic clinic 3 days after a fall from standing height at home. He reports severe left hip pain and inability to walk. Examination reveals the left lower limb in external rotation and apparent shortening of 2 cm. Radiographs show a displaced intracapsular femoral neck fracture (Garden Grade IV) with complete displacement of the femoral head fragment. The patient is medically fit for surgery with no significant comorbidities. What is the most appropriate surgical management?

Explanation

## Displaced Femoral Neck Fracture in Elderly: Hemiarthroplasty ### Clinical Context This patient has a **completely displaced intracapsular femoral neck fracture (Garden Grade IV)** in an elderly patient (82 years old). The key features are: - Complete displacement of the femoral head fragment - Disruption of blood supply to the femoral head (lateral epiphyseal vessels torn) - High risk of avascular necrosis (AVN) with any attempt at internal fixation **Key Point:** Displaced intracapsular femoral neck fractures have **union rates of only 10–30%** with ORIF due to compromised blood supply. The risk of AVN approaches 50–80%, making prosthetic replacement the gold standard in elderly patients. ### Why Hemiarthroplasty is Correct **High-Yield:** The **Garden classification** dictates management: | Garden Grade | Displacement | Age | Management | |--------------|--------------|-----|-------------| | I–II | Undisplaced | Any | ORIF (cannulated screws) | | III–IV | Displaced | <60 yrs | ORIF (attempt union) | | III–IV | Displaced | >60 yrs | **Hemiarthroplasty** | **Clinical Pearl:** In displaced fractures, the **medial and lateral femoral circumflex arteries** are torn at the fracture site, cutting off blood supply to the femoral head. Bony union becomes unlikely, and AVN is nearly inevitable. ### Hemiarthroplasty: Rationale 1. **Eliminates AVN risk** — replaces the necrotic femoral head 2. **Restores hip biomechanics** — allows immediate weight-bearing and mobilization 3. **Reduces hospital stay** — avoids prolonged bed rest and associated complications (DVT, pneumonia, delirium) 4. **Proven outcomes in elderly** — superior functional results compared to ORIF in this age group 5. **Preserves acetabulum** — avoids the need for acetabular reaming (unlike THA) **Mnemonic: HAM** — **H**emiarthroplasty for **A**vascular necrosis **M**anagement in displaced femoral neck fractures. ### Types of Hemiarthroplasty | Prosthesis | Advantages | Disadvantages | |-----------|-----------|---------------| | **Austin Moore (unipolar)** | Cheaper, simple, good for bedridden patients | Higher wear, acetabular erosion over time | | **Bipolar** | Reduces acetabular wear via inner bearing | More expensive, still some acetabular erosion | | **THA** | Best long-term outcomes, no acetabular wear | More expensive, longer operative time, not needed if acetabulum is healthy | **Tip:** In this 82-year-old with a healthy acetabulum, **bipolar hemiarthroplasty** is the most appropriate choice — it balances cost, operative time, and functional outcome. ### Why Other Options Are Incorrect **ORIF with cannulated screws (Option A):** - Union rate <30% in displaced fractures - AVN rate 50–80% - Requires repeat surgery if AVN develops - Prolongs immobility and increases medical complications - Reserved for younger patients (<60 yrs) where salvaging the femoral head is prioritized **Total Hip Arthroplasty (Option C):** - Unnecessary if acetabulum is intact and healthy - More expensive and time-consuming than hemiarthroplasty - Higher dislocation risk due to larger surgical trauma - Reserved for patients with pre-existing osteoarthritis or acetabular damage **Open reduction with plate and screws (Option D):** - Outdated and inferior to cannulated screws for femoral neck fractures - Higher soft tissue trauma - No advantage over ORIF with screws - Still carries the same high AVN and non-union risk in displaced fractures ```mermaid flowchart TD A[Femoral Neck Fracture]:::outcome --> B{Displaced?}:::decision B -->|No<br/>Garden I-II| C[ORIF with<br/>Cannulated Screws]:::action B -->|Yes<br/>Garden III-IV| D{Age?}:::decision D -->|<60 years| E[Attempt ORIF<br/>Preserve femoral head]:::action D -->|≥60 years| F[Hemiarthroplasty<br/>Bipolar preferred]:::action C --> G[Early mobilization<br/>Good union rates]:::outcome E --> H{Union achieved?}:::decision H -->|Yes| I[Functional recovery]:::outcome H -->|No/AVN| J[Revision to THA]:::urgent F --> K[Immediate weight-bearing<br/>Avoid AVN]:::outcome ``` [cite:Rockwood & Green's Fractures in Adults 9e Ch 53; Campbell's Operative Orthopaedics 13e Ch 58]