What is the management for a Garden 3 fracture?

Management of Garden 3 Femoral Neck Fractures

For Garden 3 femoral neck fractures, arthroplasty is strongly recommended over internal fixation to reduce complications and improve outcomes, particularly in elderly patients.

Patient Assessment and Initial Management

• Ensure rapid protocol-driven admission through the emergency department 1
• Provide appropriate pain management, fluid management, and plan for surgery within 48 hours of injury 1
• Implement interdisciplinary care with orthogeriatric co-management, especially for elderly patients 1

Surgical Decision Making

Age-Based Approach:

For Elderly Patients (≥65-70 years):

• Arthroplasty is strongly preferred for displaced femoral neck fractures (Garden 3-4) 1
  • Hemiarthroplasty for frail patients with shorter operative time and lower dislocation risk 1
  • Total hip arthroplasty for healthy, active, independent elderly without cognitive dysfunction 1
  • Cemented femoral stems are recommended (strong evidence) 1

For Younger Patients (<70 years):

• Internal fixation may be considered with anatomic reduction 2
• Sliding hip screw with anti-rotation screw can be used 2
• Anatomic reduction is superior to valgus reduction (lower failure rates: 4.4% vs 17.1%) 2

Anesthetic Considerations

• Either spinal or general anesthesia is appropriate (strong evidence) 1
• For spinal anesthesia:
  • Use lower doses of intrathecal bupivacaine (<10 mg) to reduce hypotension 1
  • Consider intrathecal fentanyl over morphine/diamorphine for postoperative analgesia 1
• For general anesthesia:
  • Use reduced doses of induction agents 1
  • Consider inhalational induction to maintain spontaneous ventilation 1

Perioperative Management

• Administer tranexamic acid at the start of surgery to reduce blood loss and transfusion needs 1
• Implement early thromboprophylaxis to prevent deep vein thrombosis 3
• Consider peripheral nerve blockade for supplemental pain control 3
• Implement multimodal analgesia, avoiding opioids as sole analgesics 3

Postoperative Care

• Provide appropriate pain management, antibiotic prophylaxis, and correction of postoperative anemia 1
• Conduct regular assessment of cognitive function, nutritional status, and renal function 1, 3
• Administer supplemental oxygen for at least 24 hours postoperatively 3
• Implement early mobilization to improve outcomes 1
• Remove urinary catheters as soon as possible to reduce infection risk 3

Rehabilitation and Follow-up

• Implement early postfracture physical training and muscle strengthening 1
• Continue long-term balance training and multidimensional fall prevention 1
• Conduct radiographic evaluations at regular intervals (6 weeks, 3 months, 6 months, 1 year) 3
• Full return to activities typically occurs at 3-4 months based on radiographic healing 3

Complications to Monitor

• Surgical site infection (requires aggressive antibiotic treatment) 3
• Hardware failure and non-union (more common with internal fixation) 4, 5
• Avascular necrosis (occurs in 11-25% of cases with internal fixation) 6
• Cognitive dysfunction and delirium (occurs in 25% of patients) 3

Special Considerations

• Evaluate and treat underlying osteoporosis 3
• Ensure adequate intake of calcium and vitamin D 1, 3
• Advise smoking cessation and limitation of alcohol intake 1, 3
• Educate patients about the burden of the disease, risk factors for fractures, and follow-up 1

The evidence strongly supports arthroplasty over internal fixation for Garden 3 fractures in elderly patients, with significantly lower failure rates and better functional outcomes 4. For younger patients, anatomic reduction with internal fixation may be appropriate, but requires careful technique to minimize complications 2, 5.