Garden classification

The Garden classification grades an intracapsular femoral neck fracture on the AP radiograph by how far it has displaced. Its practical value is one split: undisplaced (I and II) or displaced (III and IV).

Stage I: incomplete fracture, including the valgus-impacted type.

Stage II: complete fracture, no displacement.

Stage III: complete fracture, partial displacement. The head tilts, so its trabeculae no longer line up with the acetabulum.

Stage IV: complete fracture, full displacement. The head sits free of the neck, so its trabeculae line up again.

Undisplaced fractures are usually fixed in situ with screws or a sliding hip screw. In a young patient with a displaced fracture, the aim is to keep the patient's own head, so reduction and fixation are urgent. In an older patient the joint is replaced. NICE says to offer replacement arthroplasty to people with a displaced intracapsular fracture, using cemented implants and operating on the day of admission or the day after. It sets no age cut-off. It says to consider total hip replacement over hemiarthroplasty if the patient walked independently outdoors with no more than a stick, has no condition that makes it unsuitable, and is expected to manage daily activities independently beyond 2 years.

Do not over-trust the stages. When eight observers read 100 films, all eight agreed on only 22, and another 45 were called 'undisplaced' by some and 'displaced' by others. Garden also grades displacement, not the angle of the fracture line, which is what the Pauwels classification grades.

Viva question: A 45-year-old and a 78-year-old both have a Garden IV fracture. How does your management differ, and why?

Read more: Frandsen et al., J Bone Joint Surg Br, 1988 · NICE hip fracture guideline CG124

Education only, not medical advice. Management depends on the patient and your local protocol.