Garden reviewed low‑angle nail fixation with early weight bearing for femoral neck fractures, proposed a displacement‑based staging of subcapital fractures and asked whether the quality of reduction predicts union and avascular necrosis.
Case series from Preston Royal Infirmary: 80 subcapital fractures followed at least 12 months, plus 31 other proximal femoral fractures in patients who survived at least 6 months.
Methods
Design
Retrospective case series
Patients
80 subcapital fractures followed ≥ 12 months
31 mid‑cervical, basal or trochanteric fractures in patients surviving ≥ 6 months
Basis
Degree of displacement on radiographs
Key Findings
Of 80 subcapital fractures followed at least 12 months, 81% united, and nonunion was concentrated almost entirely in fully displaced Stage IV fractures.
Nonunion was largely limited to hips accepted with an alignment index below 155 in either the AP or the lateral view.
Avascular necrosis followed union in every hip reduced in extreme valgus (AP index above 180), and occurred only once when the AP index stayed below 180.
Garden judged that early weight bearing did not raise the rate of avascular necrosis among 80 subcapital fractures, though the series had no non‑weight‑bearing group.
Well‑defined avascular change with localized collapse appeared in 10 united fractures, and complete collapse of the head occurred once.
All 31 mid‑cervical, basal, intertrochanteric or high pertrochanteric fractures united in patients who survived at least 6 months.
Board pearl
Garden held that almost all subcapital fractures share one basic pattern, so the four stages reflect mainly how far that fracture has displaced.
Garden stages of subcapital fractureGarden, J Bone Joint Surg Br 1961
Stage I
Incomplete fracture, abducted or impacted
Union 100%. Nondisplaced, so fixed in situ.
Stage II
Complete fracture, no displacement
Union 100%. Nondisplaced, so fixed in situ.
Stage III
Complete fracture, partial displacement
Union 93% (28 of 30). Counted as displaced.
Stage IV
Complete fracture, full displacement
Union 57% (17 of 30). Counted as displaced.
Union among 80 subcapital fractures followed 12 months or more.
Authors' conclusion
It may therefore be possible to base prognosis on the quality of reduction before the fixation appliance has been inserted.
Garden reviewed low‑angle nail fixation with early weight bearing for femoral neck fractures, proposed a displacement‑based staging of subcapital fractures and asked whether the quality of reduction predicts union and avascular necrosis.
Case series from Preston Royal Infirmary: 80 subcapital fractures followed at least 12 months, plus 31 other proximal femoral fractures in patients who survived at least 6 months.
Methods
Design
Retrospective case series
Patients
80 subcapital fractures followed ≥ 12 months
31 mid‑cervical, basal or trochanteric fractures in patients surviving ≥ 6 months
Basis
Degree of displacement on radiographs
Key Findings
Of 80 subcapital fractures followed at least 12 months, 81% united, and nonunion was concentrated almost entirely in fully displaced Stage IV fractures.
Nonunion was largely limited to hips accepted with an alignment index below 155 in either the AP or the lateral view.
Avascular necrosis followed union in every hip reduced in extreme valgus (AP index above 180), and occurred only once when the AP index stayed below 180.
Garden judged that early weight bearing did not raise the rate of avascular necrosis among 80 subcapital fractures, though the series had no non‑weight‑bearing group.
Well‑defined avascular change with localized collapse appeared in 10 united fractures, and complete collapse of the head occurred once.
All 31 mid‑cervical, basal, intertrochanteric or high pertrochanteric fractures united in patients who survived at least 6 months.
Board pearl
Garden held that almost all subcapital fractures share one basic pattern, so the four stages reflect mainly how far that fracture has displaced.
Garden stages of subcapital fractureGarden, J Bone Joint Surg Br 1961
Stage I
Incomplete fracture, abducted or impacted
Union 100%. Nondisplaced, so fixed in situ.
Stage II
Complete fracture, no displacement
Union 100%. Nondisplaced, so fixed in situ.
Stage III
Complete fracture, partial displacement
Union 93% (28 of 30). Counted as displaced.
Stage IV
Complete fracture, full displacement
Union 57% (17 of 30). Counted as displaced.
Union among 80 subcapital fractures followed 12 months or more.
Authors' conclusion
It may therefore be possible to base prognosis on the quality of reduction before the fixation appliance has been inserted.