A 68-year-old man presents with a fall and pain in the left hip. An AP X-ray of the hip is obtained. The structure marked **B** in the diagram is fractured with significant displacement (Garden grade III). Which of the following is the MOST appropriate management to minimize the risk of avascular necrosis and nonunion?

Explanation

## Why Hemiarthroplasty is right The structure marked **B** is the femoral neck, which is the site of an intracapsular fracture. Displaced femoral neck fractures (Garden III–IV) carry a high risk of avascular necrosis (~30%) due to disruption of the medial circumflex femoral artery and its retinacular vessels, which are the main blood supply to the femoral head in adults. In an elderly, less active patient (age 68), hemiarthroplasty is the standard of care for displaced femoral neck fractures because it eliminates the risk of AVN by replacing the femoral head, avoids the complications of nonunion, and provides early mobilization. This is supported by Apley's Orthopaedics, which emphasizes that displaced intracapsular femoral neck fractures in the elderly are best managed by arthroplasty rather than internal fixation. ## Why each distractor is wrong - **Cannulated screws in situ**: Cannulated screws are appropriate for Garden I–II (non-displaced or minimally displaced) fractures where the blood supply is relatively preserved. In Garden III–IV displaced fractures, the vascular disruption is severe, and screw fixation risks both AVN and nonunion. This option would be incorrect for a displaced fracture. - **Dynamic hip screw (DHS) with plate**: The DHS is used for extracapsular (intertrochanteric) fractures, not intracapsular femoral neck fractures. Extracapsular fractures have preserved blood supply and do not carry the same AVN risk. Using a DHS for an intracapsular femoral neck fracture is anatomically inappropriate and does not address the vascular compromise. - **Conservative management with bed rest and traction**: Conservative management is contraindicated in displaced femoral neck fractures because it leads to high rates of nonunion, malunion, and prolonged immobility with associated complications (pneumonia, DVT, pressure sores). Early surgical intervention is mandatory. **High-Yield:** Displaced intracapsular femoral neck fractures (Garden III–IV) in elderly patients → **hemiarthroplasty**; non-displaced (Garden I–II) → **cannulated screws**; extracapsular (intertrochanteric) → **DHS or cephalomedullary nail** (no AVN risk). [cite: Apley 10e — Femoral Neck Fractures; Garden Classification and Management]