A 72-year-old woman with osteoporosis presents to the emergency department 6 hours after a fall at home. She complains of severe pain in the left hip and is unable to bear weight. On examination, the left leg is held in external rotation and appears shortened. X-ray confirms a displaced intracapsular fracture of the neck of femur. She is medically fit for surgery. What is the most appropriate next step in management?

Explanation

## Management of Displaced Intracapsular Neck of Femur Fracture ### Pathophysiology & Urgency Displaced intracapsular fractures of the femoral neck carry a high risk of avascular necrosis (AVN) due to disruption of the medial and lateral femoral circumflex arteries, which supply the femoral head. The blood supply is retrograde and tenuous in this region. **Key Point:** Displaced intracapsular fractures require urgent surgical intervention to restore blood flow and prevent AVN. Delay increases the risk of nonunion and osteonecrosis. ### Why Internal Fixation is Optimal | Feature | Displaced Intracapsular Fracture | |---------|----------------------------------| | **Vascular supply risk** | Very high (capsule disrupted) | | **Nonunion risk** | High (30–50% if untreated) | | **AVN risk** | High (up to 30% even with surgery) | | **Gold standard treatment** | Internal fixation (cannulated screws) | | **Timing** | Within 24–48 hours (ideally <24 h) | | **Implant choice** | 3 cannulated screws or dynamic hip screw | **High-Yield:** In a medically fit patient with a displaced intracapsular fracture, the goal is to restore anatomical alignment and blood flow as quickly as possible. Delay of >48 hours significantly increases AVN risk. ### Surgical Timing Algorithm ```mermaid flowchart TD A[Displaced intracapsular NOF fracture]:::outcome --> B{Medically fit for surgery?}:::decision B -->|Yes| C[Urgent fixation within 24-48 hrs]:::action B -->|No| D[Optimize medical status]:::action C --> E[Cannulated screws or DHS]:::action D --> F[Reassess fitness; delay increases AVN risk]:::outcome E --> G[Early mobilization & physiotherapy]:::action ``` **Clinical Pearl:** Even in elderly patients, the risk of AVN from delay often outweighs the operative risk. Early fixation allows early weight-bearing and reduces complications of immobility (pneumonia, DVT, pressure ulcers). ### Why Other Options Are Suboptimal **Skeletal traction** — Historical approach; now obsolete for displaced fractures. Traction does not restore blood supply and delays definitive fixation, increasing AVN risk. **Conservative management** — Contraindicated in displaced fractures. Will result in nonunion, malunion, and high morbidity from prolonged immobility. **MRI before surgery** — Unnecessary delay. X-rays are sufficient to diagnose and classify the fracture. MRI does not change management in a displaced fracture requiring urgent fixation.