A 78-year-old woman with a history of hypertension and type 2 diabetes mellitus sustains a subcapital fracture of the femoral neck (Garden grade II) following a mechanical fall. She is brought to the hospital 8 hours post-injury. On examination, the affected limb is held in external rotation and slight flexion. Plain radiographs confirm a non-displaced intracapsular fracture. Which of the following is the most appropriate management strategy for this patient, considering her age, fracture pattern, and the risk of complications?

Explanation

## Optimal Management of Non-Displaced Intracapsular Femoral Neck Fracture ### Fracture Classification Context Garden grade II fractures represent non-displaced or minimally displaced intracapsular femoral neck fractures. The subcapital location and non-displaced nature are critical determinants of management strategy. **Key Point:** Non-displaced intracapsular femoral neck fractures (Garden I–II) have a significantly lower risk of avascular necrosis (AVN) compared to displaced fractures, making preservation of the femoral head the primary goal. ### Why Closed Reduction and Internal Fixation is Optimal Closed reduction and internal fixation (CRIF) with cannulated screws is the gold standard for non-displaced intracapsular femoral neck fractures in elderly patients for the following reasons: 1. **Preserves femoral head vascularity**: The non-displaced nature means the blood supply from the medial and lateral femoral circumflex arteries remains largely intact. ORIF maintains this anatomy. 2. **Lower AVN risk**: Non-displaced fractures have AVN rates of 10–15% with ORIF, compared to 30–50% with displaced fractures. 3. **Maintains hip biomechanics**: Preserves normal hip joint mechanics and avoids the long-term complications of arthroplasty (wear, loosening, revision surgery). 4. **Screw configuration**: Three cannulated screws in an inverted triangle (or inverted Y) configuration provide optimal mechanical stability and compression across the fracture site. 5. **Age-appropriate**: Even at 78 years, if the patient is medically fit and has reasonable life expectancy, hip preservation is preferable to arthroplasty. ### Technical Considerations ```mermaid flowchart TD A[Intracapsular FNF]:::outcome --> B{Displaced?}:::decision B -->|No Garden I-II| C[CRIF with cannulated screws]:::action B -->|Yes Garden III-IV| D[Arthroplasty consideration]:::action C --> E[Inverted triangle config]:::action E --> F[Compression & stability]:::outcome D --> G{Age & comorbidity?}:::decision G -->|Young/fit| H[ORIF if possible]:::action G -->|Elderly/unfit| I[Hemiarthroplasty]:::action ``` **High-Yield:** The inverted triangle configuration of three screws provides superior biomechanical stability compared to two screws, reducing non-union and malunion rates. ### Timing of Surgery Although the patient presented 8 hours post-injury, CRIF should be performed as soon as feasible (ideally within 24–48 hours) to minimize the risk of further displacement and to allow early mobilization, which reduces complications like deep vein thrombosis and pneumonia. ### Why Other Options Are Suboptimal **Conservative management (bed rest and traction):** This approach is associated with high rates of non-union (up to 30%), malunion, and AVN. Prolonged immobility in an elderly patient increases the risk of thromboembolic events, pneumonia, and pressure ulcers. Current evidence strongly favors operative management. **Hemiarthroplasty:** Indicated for displaced intracapsular fractures (Garden III–IV) or when ORIF is contraindicated. In a non-displaced fracture, hemiarthroplasty unnecessarily sacrifices the femoral head and introduces the long-term complications of arthroplasty (wear, loosening, acetabular erosion). It is not the first-line choice for non-displaced fractures. **Total hip arthroplasty (THA):** Reserved for patients with pre-existing hip osteoarthritis or those with displaced fractures in whom hemiarthroplasty is planned. In a non-displaced fracture without hip pathology, THA is overtreatment and exposes the patient to unnecessary operative morbidity and future revision surgery. **Clinical Pearl:** The Garden classification directly guides management: Garden I–II (non-displaced) → ORIF; Garden III–IV (displaced) → Arthroplasty (hemiarthroplasty in elderly, ORIF in young fit patients). **Mnemonic: CRIF-3 for non-displaced FNF** — **C**losed **R**eduction **I**nternal **F**ixation with **3** cannulated screws is the standard for Garden I–II fractures.