A 65-year-old man with diabetes and hypertension sustains a minimally displaced (Garden Grade I) fracture of the femoral neck after a mechanical fall. He is haemodynamically stable and has no other injuries. Plain radiographs are clear. What is the most appropriate next step in management?

Explanation

## Management of Minimally Displaced (Garden Grade I–II) Intracapsular Neck of Femur Fracture ### Classification & Risk Stratification | Garden Grade | Displacement | Vascular Risk | Treatment | |--------------|--------------|---------------|----------| | **I–II** | Minimal/none | Moderate | Percutaneous pinning / internal fixation | | **III–IV** | Complete | High | Urgent internal fixation (cannulated screws/DHS) | **Key Point:** Minimally displaced intracapsular fractures (Garden I–II) have better blood supply preservation than completely displaced fractures. However, they still require operative fixation to prevent displacement and nonunion. ### Why Percutaneous Pinning Is Optimal Percutaneous pinning (or minimally invasive internal fixation with cannulated screws) is the gold standard for Garden I–II fractures because: 1. **Minimal soft tissue trauma** — Preserves remaining blood supply to the femoral head 2. **Lower morbidity** — Smaller incisions, reduced infection risk, faster recovery 3. **Early mobilization** — Allows weight-bearing as tolerated within days 4. **High union rates** — 85–95% in minimally displaced fractures with early fixation 5. **Prevents displacement** — Stabilizes the fracture before it progresses to Grade III–IV **High-Yield:** The key difference between minimally and completely displaced fractures is the timing and approach. Minimally displaced fractures can be managed with percutaneous techniques, while completely displaced fractures often require open reduction and more robust fixation (cannulated screws or DHS). ### Management Algorithm for Intracapsular NOF Fractures ```mermaid flowchart TD A[Intracapsular NOF fracture]:::outcome --> B{Garden Grade?}:::decision B -->|Grade I-II<br/>Minimally displaced| C[Percutaneous pinning<br/>or cannulated screws]:::action B -->|Grade III-IV<br/>Completely displaced| D[Urgent open reduction<br/>+ internal fixation]:::action C --> E[Early weight-bearing<br/>as tolerated]:::action D --> E E --> F[Physiotherapy &<br/>mobilization]:::action F --> G[Monitor for AVN<br/>at 6-12 months]:::outcome ``` **Clinical Pearl:** Even minimally displaced fractures can displace over time if left untreated. Early operative fixation within 24–48 hours prevents this progression and reduces nonunion risk from 10–15% to <5%. ### Why Other Options Are Suboptimal **Immediate open fixation** — Unnecessarily invasive for a minimally displaced fracture. Percutaneous pinning achieves the same outcome with less morbidity. **Conservative management** — Contraindicated. Even Grade I fractures have a 10–15% nonunion rate if treated conservatively. Prolonged bed rest increases complications (DVT, pneumonia, deconditioning) in an elderly diabetic patient. **Repeat imaging before surgery** — Unnecessary delay. The fracture pattern is already clear on initial X-rays. Waiting 2 weeks risks displacement, increasing complexity and AVN risk.