Current Trends in the Evaluation and Management of Nondisplaced Femoral Neck Fractures in the Elderly

Kanu Okike, MD, MPH; Ian G. Hasegawa, MD


J Am Acad Orthop Surg. 2021;29(4):e154-e164. 

In This Article


Traditionally, FN fractures have been categorized using the Garden[11] classification. This classification system divides FN fractures into four types (I, II, III, and IV; Figure 1). Despite its widespread use, this classification system has been associated with poor to moderate intraobserver and interobserver reliability.[12,13] Subsequently, a simplified version consisting of nondisplaced (types I and II) and displaced (types III and IV) categories was introduced.[13] For the purpose of this review, the nondisplaced (also termed "undisplaced") fracture types have been taken to include incomplete valgus-impacted fractures (type I) and complete fractures that remain in cortical continuity with trabecular lines that also remain collinear (type II).

Figure 1.

Garden classification of femoral neck fractures. Type I fractures are valgus-impacted on the AP radiograph. Type II fractures are complete but nondisplaced, with trabecular lines that remain collinear. Type III fractures are angulated with disturbance of the trabecular pattern and no proximal translation of the shaft. Type IV fractures involve complete displacement of the fracture fragments with proximal translation of the shaft; the femoral head is free to reorient itself in the acetabulum, causing the trabeculae to realign. Garden I and II fracture types are categorized as nondisplaced (or undisplaced, as labeled in this diagram). (Reproduced with permission from White TO, et al: McRae's Orthopaedic Trauma and Emergency Fracture Management, ed 3.)

An important limitation of the original and simplified Garden[11] classification systems is that they rely exclusively on the AP radiograph. As such, displacement on the lateral view is not specifically considered when assigning the classification. As discussed below, failure to identify sagittal plane displacement can predispose to revision surgery after surgical fixation.[6,14,15] To date, no commonly used FN fracture classification system exists that considers fracture displacement in multiple planes.