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I: incomplete/valgus impacted; II: complete, nondisplaced. III: complete, partially displaced (varus); IV: complete, fully displaced. I–II stable → fixation; III–IV unstable → arthroplasty in elderly (high AVN/nonunion).
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The Garden classification (1961), developed by R.S. Garden, is the most clinically used system for grading femoral neck (intracapsular) fractures based on the DEGREE OF DISPLACEMENT of the femoral head and the alignment of the medial trabecular system. It is complementary to the Pauwels classification (which grades the mechanical angle of the fracture line) — together, Pauwels + Garden provide a complete biomechanical and displacement-based description of any femoral neck fracture. The Garden system is directly linked to AVN risk (which increases with displacement) and directly guides the clinical management decision between internal fixation and arthroplasty.
| Garden Grade | Description | Trabecular Alignment | AVN Risk | Management (Elderly) | Management (Young <60yrs) |
|---|---|---|---|---|---|
| Grade I — Incomplete / Valgus-Impacted | An INCOMPLETE fracture of the femoral neck; the inferior cortex of the neck is fractured but the superior cortex is intact; the fracture is impacted in valgus (the femoral head is impacted onto the neck in a valgus position — the neck-shaft angle appears increased); the fracture is NOT complete; the intact superior cortex acts as a `hinge` | Trabeculae aligned but angulated INTO VALGUS relative to normal (the impacted position shifts the trabecular orientation slightly); the alignment is abnormally valgus but the trabecular system is intact and continuous | LOW — ~10% AVN rate; the valgus-impacted position can decompress the intracapsular haematoma slightly; the retinacular vessels may be partially intact; however, these fractures can DISPLACE if not fixed — up to 10–20% displace when managed non-operatively | Internal fixation with 3 parallel cannulated screws; prevents displacement during mobilisation; non-operative management is associated with unacceptable displacement rates (10–20% displace); surgery prevents this | 3 cannulated screws; anatomical position usually maintained at time of fixation (the valgus impaction is the fracture`s natural position) |
| Grade II — Complete, Undisplaced | A COMPLETE fracture of the femoral neck with NO DISPLACEMENT; the fracture line is complete (both superior and inferior cortex fractured) but the fragments remain in anatomical position; the femoral head has NOT moved relative to the neck | Trabeculae ALIGNED — the medial trabecular system of the femoral head is in continuity with the neck and acetabulum; the normal orientation is maintained because the head has not displaced | LOW-MODERATE — ~15–20% AVN rate; the complete fracture has disrupted the retinacular vessels to a greater degree than Grade I, but the lack of displacement means the vessels are intact or only minimally stretched; however, the fracture is complete and can displace | Internal fixation with 3 parallel cannulated screws; the undisplaced position means no reduction is needed — fixation in situ; the screws prevent displacement and provide stability for mobilisation; arthroplasty is NOT appropriate for Grade II fractures in elderly (no displacement = low AVN risk = fixation is appropriate) | 3 cannulated screws; in situ fixation without reduction |
| Grade III — Partially Displaced | A COMPLETE fracture with PARTIAL DISPLACEMENT — the femoral head has moved but maintains some contact with the femoral neck; the femoral head is rotated and partially displaced; the neck and head are no longer in anatomical alignment but the fragments have not completely separated | Trabeculae MALALIGNED — the medial trabecular system of the femoral head is NOT aligned with the neck trabeculae (the head has rotated); the trabecular lines on the AP X-ray are discontinuous at the fracture site; the femoral head tilts into varus (the classic displaced position) | HIGH — ~30–35% AVN rate; the partial displacement has stretched and likely partially torn the retinacular vessels; the longer the fracture remains displaced, the more ischaemic damage accumulates; urgent reduction and fixation reduces AVN risk in young patients | ARTHROPLASTY for elderly (>65 years): hemiarthroplasty for low-demand patients; THA for active elderly patients with pre-existing ipsilateral OA or for very active patients; internal fixation in the elderly with displaced femoral neck fractures has a failure rate of ~30–50% from non-union + AVN → arthroplasty avoids this reoperation risk | URGENT ANATOMICAL REDUCTION + INTERNAL FIXATION within 6–12 hours; closed reduction under image intensifier; 3 cannulated screws or sliding hip screw with anti-rotation screw; anatomical reduction is critical (malreduction increases non-union risk); accept the higher AVN/non-union risk in a young patient — head preservation is the priority (`nothing to lose by trying`) |
| Grade IV — Completely Displaced | A COMPLETE fracture with FULL DISPLACEMENT — the femoral head is completely separated from the femoral neck; the femoral head has rotated freely within the acetabulum and has `escaped` the neck entirely; the neck fragment is typically displaced posterosuperiorly (driven by the deforming forces) | Trabeculae PARADOXICALLY REALIGNED — the femoral head has rotated so completely that its medial trabecular system re-aligns with the acetabular trabeculae (because the head is free within the acetabulum and rotates back to align with the joint forces); this `paradoxical alignment` is a classic radiological sign of Grade IV | VERY HIGH — ~50% AVN rate; virtually all retinacular vessels are torn by the complete displacement; the femoral head is partially or completely devascularised; even with urgent reduction and fixation in young patients, AVN is common; in elderly patients, the articular damage from attempted reduction carries its own risks | ARTHROPLASTY for elderly: hemiarthroplasty (cemented or uncemented) for lower-demand patients; THA for active elderly (60–75 years); primary THA is associated with better long-term outcomes and lower revision rates than hemiarthroplasty in active elderly patients; cemented hemiarthroplasty provides more immediate stability in very frail elderly patients | URGENT CLOSED REDUCTION + INTERNAL FIXATION (same as Grade III); anatomical reduction within 6 hours; 3 cannulated screws; accept the AVN risk in young patients — head preservation is paramount; if closed reduction fails → open reduction via anterior or posterior approach |
| Patient Group | Garden I/II (Undisplaced) | Garden III/IV (Displaced) |
|---|---|---|
| Elderly (>65 years) | Internal fixation (3 cannulated screws) — the undisplaced position means low AVN risk; fixation prevents displacement; hemiarthroplasty is an alternative if bone quality is very poor or the patient cannot tolerate the risk of late displacement | ARTHROPLASTY — hemiarthroplasty for low-demand patients; THA for active elderly; the HIGH failure rate of fixation (>30% non-union + AVN) in displaced fractures in elderly patients makes arthroplasty the first-line treatment; avoids reoperation |
| Young (<60 years) | Internal fixation (3 cannulated screws) — definitive treatment; head preservation is the priority; long-term arthroplasty durability in young patients is poor | URGENT ANATOMICAL REDUCTION + FIXATION within 6–12 hours; every attempt to preserve the femoral head is made; accept higher AVN/non-union risk; arthroplasty is a salvage option if fixation fails |
| Middle-aged (60–65 years) | Internal fixation (screws) | INDIVIDUALISED — consider activity level, bone quality, cognitive function, contralateral hip; either urgent ORIF (head preservation attempt) or arthroplasty based on discussion with patient |
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