4. Femoral Neck Fracture: Garden Classification and Disposition
Case Presentation
A 78-year-old woman presents after a low-energy fall from standing. She is unable to bear weight on the right leg. Examination reveals the right lower limb is shortened and externally rotated. She is hemodynamically stable with no open wounds. Anteroposterior (AP) and lateral radiographs of the pelvis and right hip are obtained.
Radiographic findings: a fracture line traverses the femoral neck. On the AP view, the primary fracture line runs from the subcapital region obliquely across the neck. The femoral head is displaced relative to the neck, and the trabecular lines within the head do not align with those of the acetabulum. On the lateral view, the head is rotated posteriorly, and there is clear translation between the head and neck fragments.
Applying the Garden Classification
The Garden classification grades femoral neck fractures by the degree of displacement, using the orientation of the primary trabeculae in the femoral head relative to the acetabulum as the key radiographic landmark. The classification is applied to AP and lateral views together; the lateral view is essential because it reveals posterior tilt and translation that the AP view may underestimate.
| Garden Stage | Radiographic Criteria | Displacement | Typical Management |
|---|---|---|---|
| I | Incomplete fracture; trabeculae in the head are angled but not fully disrupted; valgus-impacted | Undisplaced | Conservative (protected weight-bearing) in selected low-demand patients; internal fixation if displacement risk is high |
| II | Complete fracture line; trabeculae remain aligned; no translation | Undisplaced | Internal fixation (cannulated screws) in most patients |
| III | Complete fracture; trabeculae no longer aligned; partial displacement | Partially displaced | Arthroplasty in older patients; internal fixation in younger patients |
| IV | Complete fracture; trabeculae completely displaced; full translation | Fully displaced | Arthroplasty (hemiarthroplasty or total hip arthroplasty) in older patients |
In this case, the AP view shows a complete fracture line with loss of trabecular alignment and partial translation; the lateral view confirms posterior displacement of the head. This corresponds to a Garden III fracture. The key distinction from Garden II is the loss of trabecular continuity across the fracture; the distinction from Garden IV is that the head remains partially in contact with the neck rather than being fully translated.
Disposition Decision for This Patient
The patient is 78 years old, previously ambulatory, and lives independently. Her Garden III fracture is displaced, which carries a high risk of avascular necrosis and nonunion if treated with internal fixation alone. The blood supply to the femoral head runs retrograde along the neck; displacement shears these retinacular vessels, and the risk of head collapse rises sharply with increasing Garden stage.
For a displaced femoral neck fracture in an older patient, the evidence supports arthroplasty rather than internal fixation. The choice between hemiarthroplasty and total hip arthroplasty depends on pre-injury function and expected longevity:
- Hemiarthroplasty is appropriate for lower-demand, frail patients or those with limited life expectancy. It replaces the head but preserves the acetabulum, reducing operative time and dislocation risk.
- Total hip arthroplasty (THA) is preferred for independently ambulatory patients with good cognitive function and reasonable life expectancy, as it provides better long-term function and lower revision rates for acetabular wear.
Given this patient's independent mobility and lack of cognitive impairment, total hip arthroplasty is the recommended disposition. She should be optimized medically (anticoagulation prophylaxis, pressure-area care, early mobilization) and undergo surgery within 24–48 hours where feasible, as delayed surgery in older hip fracture patients is associated with higher complication rates.
Verification and Expected Course
Postoperative verification includes confirming implant position on AP and lateral radiographs, assessing leg-length restoration, and monitoring for complications: dislocation (especially with posterior approach), periprosthetic fracture, and thromboembolic events. Expected functional milestones are protected weight-bearing on day 1 with a walker, progressing to independent ambulation over 6–12 weeks with physiotherapy. A drop in hemoglobin, new groin pain, or inability to weight-bear should prompt reassessment for hematoma, dislocation, or infection.