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Garden I & II: Diagnosis and Treatment

- See: Garden Alignment Index

- Garden I:
    - incomplete or impacted fracture, in which the trabeculae of the inferior neck are still intact;
    - femoral head is tilted in a posterolateral direction, causing vaglus angulation at the frx site;
    - non surgical treatment:
         - some advocate non operative treatment for these injuries, noting that the frx is incomplete and
                   results in spontaneous healing in over 80% of patients;
         - however, these fractures are often painful, and that cannulated screw fixation offers substantial and
                   immediate pain relief;
         - ref: [Femur-neck abduction fractures.]
                   - Not All Garden-I and II Femoral Neck Fractures in the Elderly Should Be Fixed
    - surgical treatment of garden I:
         - no attempt is made to disimpact the fracture;
         - fixation is performed w/ cannulated screws in situ;
         - as an alternative consider use of multiple pins
         - larger implants, such as compression hip screws or other nail plate devices, may increase risk of disimpaction at surgery and
                    are to be avoided;
         - surgery can be performed on a fracture table or can be performed in the lateral position on a flouro table;
                - if surgery is to be performed in the lateral position, then the lateral radiograph is obtained by flexing and externally
                       rotating the hip (frog leg lateral);
                       - note that it not uncommon to find that the fracture displaces into retroversion in the frog lateral position;
                       - this means that the guide pins need to be inserted prior to obtaining a lateral radiograph;
         - ref: Articular penetration is more likely in Garden I fractures of the hip.

    - complications:
         - AVN develops in 10-40% of these frxs w/ or w/o internal fixation;
                - results from extreme valgus position, which causes kinking of lateral epiphyseal vessels & medial epiphyseal vessels in
                           ligamentum teres as the head;
         - non union:
                - as pointed out by Hammer (1992), only 1/83 pts w/ Garden I fractures, developed a non union;


    - case example:
          - in the next example, the pins were placed at the correct level but could have been angled more superiorly in order to engage
                    the central portion of the femoral head;


- Garden II:
    - complete frx w/o displacement (as opposed to stress frx)
    - wt bearing trabeculae are interrupted by a frx line across entire femoral neck;
    - is distinguished from impacted frx by slight varus deformity (see: alignment index);
    - since Garden II fractures are not impacted, there is no bony stability, and hence displacement will occur unless it is
             internally fixed;
    - treated w/ closed reduction & internal fixation w/ either cannulated screws or pins;
    - risk of non union:
         - as pointed out by Hammer (1992), all Garden 2 fractures w/ transverse frx line went on to heal, where as 2/5 fractures w/ a
                    vertical configuration went on to non union


Three cancellous bone screws versus a screw-angle plate in the treatment of Garden I and II fractures of the femoral neck.

Nonunion of Subcapital Femoral Neck Fractures.

Non-operative treatment of impacted femoral neck fractures. A prospective study of 170 cases.

Reduction and fixation of subcapital fractures of the femur.

- example of normal hip: