A 65-year-old man with a displaced intracapsular femoral neck fracture is being counseled on treatment options. His orthopedic surgeon explains that the fracture pattern determines whether the femoral head can be salvaged. Which finding best distinguishes a fracture that is amenable to open reduction and internal fixation (ORIF) from one requiring hemiarthroplasty in an elderly patient?

Explanation

## Garden Classification: Predicting Salvageability in Intracapsular Femoral Neck Fractures ### The Garden Classification System **Key Point:** The Garden classification is the gold standard for assessing intracapsular femoral neck fractures and predicting which fractures can be salvaged with ORIF versus those requiring hemiarthroplasty. ### Garden Classification Grades | Grade | Description | Displacement | Prognosis | Treatment | | --- | --- | --- | --- | --- | | **I** | Incomplete (valgus impacted) | None | Excellent | Conservative or percutaneous pinning | | **II** | Complete, non-displaced | None | Good | ORIF with cannulated screws | | **III** | Complete, partially displaced | Partial | Fair | ORIF (attempted), but higher non-union risk | | **IV** | Complete, fully displaced | Complete | Poor | Hemiarthroplasty (elderly) or ORIF (young) | ### Clinical Decision-Making **High-Yield:** In elderly patients (>70 years): - **Garden I–II** → ORIF with cannulated screws (good healing potential) - **Garden III–IV** → Hemiarthroplasty (vascular compromise too severe for salvage) In young patients (<50 years): - **All grades** → ORIF attempted (preserve femoral head for longevity) ### Why Garden Classification Discriminates 1. **Displacement degree correlates with vascular injury** - Non-displaced (Grade I–II) → vessels may remain intact → salvageable - Fully displaced (Grade IV) → vessels torn → head becomes avascular → non-salvageable 2. **Predicts union rate** - Grade I–II: 95–100% union - Grade III: 80–90% union - Grade IV: 10–20% union (hence hemiarthroplasty preferred in elderly) 3. **Guides timing and implant choice** - Grades I–II: Percutaneous pinning or ORIF with screws - Grade IV: Hemiarthroplasty (avoid prolonged immobilization in elderly) ### Clinical Pearl **Mnemonic:** **GARDEN** = **G**rade determines **A**ge-based **R**esult: **D**isplaced → **E**lderly → **N**eed arthroplasty. - Grade I–II (non-displaced) in elderly → ORIF - Grade III–IV (displaced) in elderly → Hemiarthroplasty [cite:Rockwood & Green's Fractures in Adults 9e Ch 48]