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A 78-year-old woman falls at home. She has severe right hip pain and cannot weight-bear. On examination: right leg is shortened and externally rotated. X-ray shows a displaced Garden IV intracapsular femoral neck fracture.
Questions
a) What is the classic clinical deformity and why does it occur? (2 marks)
Shortened and externally rotated limb. The fracture displaces, the femoral shaft rides upwards (shortening) due to muscle pull (gluteals, psoas), and external rotation occurs because the femoral neck no longer stabilises the femur in the acetabulum, allowing external rotators to rotate the limb externally.
b) Describe the Garden classification and classify this fracture. (3 marks)
Garden classification of intracapsular NOF fractures:
- Garden I: Incomplete/valgus impacted (undisplaced)
- Garden II: Complete but undisplaced
- Garden III: Complete, partially displaced (varus tilt)
- Garden IV: Complete, fully displaced — fragments not in contact
This patient has a Garden IV fracture (fully displaced).
c) What is the optimal surgical management for this patient? (3 marks)
Hemiarthroplasty (for elderly, less active patients) OR total hip replacement (for active, independently mobile patients). Internal fixation (cannulated screws) is NOT recommended for displaced Garden III-IV fractures due to high rates of AVN (30-40%) and non-union.
d) What are the key peri-operative considerations? (2 marks)
- Surgery within 36 hours (NICE) — delays increase mortality
- Optimisation: cardiac, respiratory, fluid balance
- VTE prophylaxis: LMWH or DOAC
- Bone health: DEXA scan, bisphosphonate therapy for underlying osteoporosis
- Multidisciplinary: orthogeriatric input
- 30-day mortality: approximately 10%; 1-year mortality: approximately 30%