Classification system
Garden Classification
Garden Classification of Femoral Neck Fractures
The Garden classification grades intracapsular femoral neck fractures into four types by the completeness of the fracture line and the degree of displacement on an anteroposterior radiograph, where types I and II are non-displaced and types III and IV are displaced.
What the Garden category means
Garden scores run from 1 to 4, where a lower score is better. The bands below are conventional reporting categories, not diagnostic cut-offs.
- Non-displaced (Garden I–II)1–2
Usually managed with internal fixation.
- Displaced (Garden III–IV)3–4
Usually managed with arthroplasty in older patients; fixation is considered in younger patients as an urgent procedure.
Published criteria and reliability
The published cut-offs that define this instrument, and the measured agreement between observers using it. Each is reported with the population it was derived in.
| Type | Value | Subscale | Population | Follow-up | Source |
|---|---|---|---|---|---|
| Criterion | Interobserver kappa 0.27–0.56 for the four-type system | — | Orthopaedic surgeons and radiologists | — | Frandsen PA 1988 |
| Criterion | Kappa improves to 0.68–0.79 for the two-group system | — | Non-displaced versus displaced | — | Oakes DA 2003 |
Criterion is a published cut-off, definition or performance figure belonging to a classification or decision rule — it is not a change score and should not be read as one.
How the score is calculated
Stated in full so the calculation can be independently checked, and reproduced by hand if needed.
Garden I is an incomplete or valgus-impacted fracture. Garden II is a complete fracture without displacement. Garden III is a complete fracture with partial displacement, in which the femoral head is tilted into varus and its medial trabeculae are not aligned with those of the acetabulum. Garden IV is a complete fracture with full displacement, in which the head fragment returns to its neutral position and its trabeculae realign with the acetabular trabeculae. The practical distinction that drives treatment is non-displaced (I–II) versus displaced (III–IV).
Instrument profile
- Developer
- Robert S. Garden
- Institution
- Preston Royal Infirmary, United Kingdom
- First published
- 1961
- Items
- 2
- Response format
- Branching radiographic assessment
- Score range
- 1 to 4
- Direction
- Lower score = better
- Completion time
- About 1 minutes
- Regions
- Hip
- Conditions
- Femoral neck fracture, Intracapsular hip fracture, Hip fracture
- Procedures
- Cannulated screw fixation, Hemiarthroplasty, Total hip arthroplasty
- Validity
- Displacement grade correlates with the risk of avascular necrosis and non-union, which is the reason the classification has endured.
- Reliability
- Reliability of the full four-type system is only fair; the collapsed two-group system is substantially more reliable and is what most trials report.
When to use the Garden
Well suited to
- Classifying an intracapsular femoral neck fracture to guide the choice between fixation and arthroplasty.
- Reporting fracture severity in research and registries, where the two-group form is preferred.
Limitations and poor fits
- Extracapsular fractures — intertrochanteric and subtrochanteric patterns are not covered by this system.
- As a sole determinant of treatment: patient age, bone quality, functional demand and time from injury all bear on the decision.
Garden compared with other instruments
Instruments measuring a related construct, with the practical difference between them.
| Instrument | Items | Range | What it adds |
|---|---|---|---|
| Pauwels | 1 | 0–90 | The Pauwels classification grades an intracapsular femoral neck fracture by the angle between the fracture line and the horizontal plane on an anteroposterior radiograph — type I below 30°, type II from 30° to 50°, and type III above 50° — because the more vertical the fracture, the greater the shear component across it and the higher the risk of fixation failure. |
| AO/OTA | 3 | 1–3 | The AO/OTA classification gives every fracture an alphanumeric code in which the first digit is the bone, the second the segment and the letter the fracture type — extra-articular, partial articular or complete articular in an end segment, and simple, wedge or multifragmentary in a shaft — so that 32-A is a simple femoral shaft fracture and 43-C a complete articular pilon fracture. |
Copyright and permitted use
Published openly because it is the question every clinician and researcher asks before using an instrument, and almost nobody answers it.
A published radiographic classification system. No licence is required.
References
- Garden RS. Low-angle fixation in fractures of the femoral neck. Journal of Bone and Joint Surgery (British). 1961.
- Frandsen PA, Andersen E, Madsen F, Skjødt T. Garden’s classification of femoral neck fractures: an assessment of inter-observer variation. Journal of Bone and Joint Surgery (British). 1988.PMID 3372581
- Oakes DA, Jackson KR, Davies MR, et al.. The impact of the Garden classification on proposed operative treatment. Clinical Orthopaedics and Related Research. 2003.PMID 12782863
Editorial status
This page has not yet been signed off by a named clinical reviewer. The scoring logic is stated in full above so it can be independently verified, and every threshold is traceable to its source. See our editorial methodology.