A 72-year-old woman with osteoporosis presents to the emergency department 6 hours after a fall at home. Plain radiographs reveal a displaced intracapsular fracture of the femoral neck (Garden grade III). She is hemodynamically stable and medically fit for surgery. Which of the following is the single best management approach for this patient?

Explanation

## Management of Displaced Intracapsular Femoral Neck Fracture ### Classification Context **Key Point:** Intracapsular femoral neck fractures are classified using the Garden classification system: - **Garden I–II:** Undisplaced or minimally displaced - **Garden III–IV:** Displaced fractures This patient has a **Garden grade III** (displaced) intracapsular fracture, which carries a high risk of avascular necrosis (AVN) due to disruption of the blood supply to the femoral head. ### Why Total Hip Arthroplasty Is Correct **High-Yield:** In elderly patients (typically >60–70 years) with displaced intracapsular femoral neck fractures, **total hip arthroplasty (THA) is the gold standard** because: 1. **High AVN risk:** Displaced intracapsular fractures disrupt the lateral epiphyseal vessels, which are the primary blood supply to the femoral head. The incidence of AVN after displaced intracapsular fractures is 10–30% with ORIF, compared to near-zero with THA. 2. **Functional outcome:** THA restores a more normal hip biomechanics and provides superior functional outcomes in the long term compared to ORIF with its risk of nonunion and AVN. 3. **Age and bone quality:** At 72 years with osteoporosis, the patient is at high risk for nonunion and implant failure with internal fixation alone. THA bypasses these concerns. 4. **Cemented vs. uncemented:** Cemented prostheses are preferred in elderly patients with poor bone quality because they provide immediate stability and reduce the risk of aseptic loosening. **Clinical Pearl:** The decision between ORIF and arthroplasty hinges on: - **Age:** >60–65 years → THA preferred - **Displacement:** Garden III–IV → THA preferred - **Bone quality:** Poor (osteoporosis) → THA preferred ### Treatment Algorithm ```mermaid flowchart TD A[Femoral Neck Fracture]:::outcome --> B{Intracapsular or Extracapsular?}:::decision B -->|Intracapsular| C{Displaced?}:::decision B -->|Extracapsular| D[ORIF with DHS]:::action C -->|Undisplaced<br/>Garden I-II| E[Percutaneous pinning<br/>or screw fixation]:::action C -->|Displaced<br/>Garden III-IV| F{Patient age & fitness?}:::decision F -->|Young<br/>< 60 yrs| G[ORIF with screws<br/>accept AVN risk]:::action F -->|Elderly<br/>> 60-70 yrs| H[Total Hip Arthroplasty]:::action H --> I[Cemented prosthesis<br/>if poor bone quality]:::action E --> J[Monitor for nonunion<br/>& AVN]:::outcome G --> K[High AVN risk<br/>10-30%]:::urgent I --> L[Superior long-term<br/>functional outcome]:::outcome ``` ### Comparison of Management Options | Feature | Percutaneous Pinning | ORIF (DHS) | THA (Cemented) | |---------|----------------------|------------|----------------| | **Indication** | Undisplaced (Garden I–II) | Extracapsular; young patients with displaced intracapsular | Elderly with displaced intracapsular | | **AVN risk** | Low (5–10%) | High (10–30%) | Minimal (0–2%) | | **Nonunion risk** | 5–15% | 10–20% | None | | **Functional outcome** | Good if union achieved | Good if no AVN | Excellent | | **Revision rate** | Low | Moderate (if AVN/nonunion) | Moderate at 10–15 years | | **Bone quality dependence** | Moderate | High | Low | ### Why This Patient Specifically Needs THA 1. **Age 72:** Beyond the threshold where ORIF complications (AVN, nonunion) become unacceptable 2. **Osteoporosis:** Poor bone stock makes internal fixation unreliable 3. **Garden III displacement:** High-energy injury pattern with disrupted blood supply 4. **Medically fit:** No contraindications to surgery; can tolerate THA **Mnemonic:** **AVON** = **A**ge >60, **V**ascular disruption (displaced), **O**steoporosis, **N**eed for arthroplasty. ### Cemented vs. Uncemented in This Case **Cemented prosthesis is preferred** because: - Immediate stability in poor bone quality - Lower risk of aseptic loosening in elderly patients - Better functional outcome in the first 5–10 years - Easier revision if needed later ## Summary In an elderly patient with a **displaced intracapsular femoral neck fracture and osteoporosis**, **total hip arthroplasty with a cemented prosthesis** offers the best balance of: - Eliminating AVN risk - Avoiding nonunion - Restoring function - Accommodating poor bone quality [cite:Campbell's Operative Orthopaedics 13e Ch 55; Rockwood & Green's Fractures in Adults 9e Ch 48]