A 72-year-old woman from Delhi presents to the emergency department with severe pain in the left hip and inability to bear weight after a fall from standing height while walking in her garden. On examination, the left leg is held in flexion, adduction, and internal rotation. Hip movements are restricted and painful. X-ray pelvis shows a fracture of the femoral neck with the fracture line extending across the neck proximal to the intertrochanteric line. There is no displacement of the fracture fragments. What is the Garden classification grade of this fracture?

Explanation

## Garden Classification of Femoral Neck Fractures The Garden classification system is the most widely used grading system for femoral neck fractures based on the degree of displacement and angulation. ### Classification Grades | Grade | Displacement | Angulation | Fracture Pattern | Prognosis | |-------|--------------|-----------|------------------|----------| | I | None | None | Incomplete (stress fracture) | Excellent | | II | None | None | Complete, no displacement | Good | | III | Partial | Present | Partial displacement, angulation | Fair–Poor | | IV | Complete | Present | Full displacement, no cortical contact | Poor | **Key Point:** Grade II fractures are complete fractures that cross the entire femoral neck WITHOUT any displacement of the fracture fragments. The fracture line extends completely across the neck (ruling out Grade I), but the fragments remain anatomically aligned (ruling out Grades III and IV). **High-Yield:** The distinction between Grade II and Grade III is critical: - **Grade II:** Complete fracture, NO displacement → better blood supply preserved → higher union rate (80–90%) - **Grade III:** Partial displacement visible → compromised blood supply → higher nonunion/AVN risk (30–40%) **Clinical Pearl:** In this case, the X-ray explicitly states "no displacement of the fracture fragments" despite the fracture line extending across the neck proximal to the intertrochanteric line. This is the hallmark of a Grade II fracture. ### Management Implications Grade II fractures have a relatively favorable prognosis because: 1. The blood supply to the femoral head is better preserved when fragments are not displaced 2. Internal fixation with cannulated screws (3 screws in a triangular pattern) is the standard of care 3. Union rates are higher compared to displaced fractures (Grade III–IV) 4. Risk of avascular necrosis (AVN) is lower (~10–15% vs. 30–50% in Grade III–IV) **Mnemonic:** **GARDEN** = **G**rade **A**ssesses **R**eal **D**isplacement **E**xtent **N**ow - Grade I = **I**ncomplete - Grade II = **II** = Complete, **No** displacement (remember: "II" looks like two intact lines) - Grade III = **III** = Three fragments or partial displacement - Grade IV = **IV** = **F**ull displacement (4 = complete separation) [cite:Rockwood and Green's Fractures in Adults, 9e Ch 51]