Garden IV: Definition, Uses, and Clinical Overview

Posted on February 27, 2026 | by drhip

Garden IV Introduction (What it is)

Garden IV is a category in the Garden classification for femoral neck fractures.
It describes a fully displaced fracture of the femoral neck with complete loss of alignment.
The term is most commonly used in emergency care and orthopedic surgery to communicate severity.
It helps guide discussion of likely management pathways and risks.

Why Garden IV used (Purpose / benefits)

Garden IV is used to describe the most displaced end of intracapsular femoral neck fractures (fractures within the hip joint capsule). The purpose is not to “treat” anything directly, but to classify the injury in a standardized way so clinicians can communicate clearly and plan evaluation and care.

In general terms, identifying a fracture as Garden IV helps clinicians:

Recognize severity and instability. A Garden IV fracture is displaced, meaning the femoral head and femoral neck are no longer aligned as they normally are.
Anticipate blood-supply concerns. Femoral neck fractures can affect blood flow to the femoral head; displacement is one factor that can increase concern for complications related to blood supply.
Support decision-making about operative strategies. Management for displaced intracapsular fractures often differs from nondisplaced fractures, and classification helps structure that conversation.
Standardize communication across teams. Radiologists, emergency clinicians, orthopedic surgeons, and physical therapists may all use the term to quickly convey what the imaging shows.
Facilitate documentation, research, and quality tracking. Classifications like Garden are commonly used in studies and registries to group similar injuries.

Garden IV is best thought of as a “shared language” that summarizes what the fracture looks like and why it matters clinically.

Indications (When orthopedic clinicians use it)

Orthopedic clinicians and radiologists commonly apply the Garden classification (including Garden IV) in scenarios such as:

Suspected femoral neck fracture after a fall, especially in older adults
High-energy trauma (e.g., vehicle collision) causing hip pain and inability to bear weight
Hip pain with a shortened, externally rotated leg on exam (a common pattern with displaced hip fractures)
Confirmed intracapsular fracture on X-ray, with further characterization on additional imaging when needed
Preoperative planning and documentation for surgical management discussions
Post-injury communication between hospital teams and rehabilitation services

Contraindications / when it’s NOT ideal

Garden IV is a descriptive label, not a treatment, so “contraindications” mainly refer to situations where it may not be the most suitable classification tool or where it may be difficult to apply reliably:

Non–femoral neck hip fractures, such as intertrochanteric or subtrochanteric fractures, where other classification systems are more appropriate
Extracapsular fractures, where the Garden system does not apply
Poor-quality or non-standard radiographs, where displacement and alignment are hard to assess
Occult or minimally visible fractures (symptoms suggest fracture but X-rays are negative), where advanced imaging may be needed before classification
Cases where another framework better captures fracture behavior, such as:
Pauwels classification (emphasizes fracture angle and shear forces)
Descriptions of comminution (multiple fragments) or associated injuries not captured by Garden staging

Even when used, Garden staging can show variation between readers, particularly at the borders between categories. Varies by clinician and case.

How it works (Mechanism / physiology)

Garden IV reflects a specific biomechanical and anatomic situation: a displaced intracapsular femoral neck fracture with complete loss of continuity between the femoral head and the femoral shaft/neck alignment.

Biomechanical principle

In Garden IV, the fracture is fully displaced, meaning normal load transfer through the femoral neck is disrupted.
Because the fracture is unstable, normal standing and walking forces can worsen displacement, which is one reason these injuries are typically treated urgently in hospital settings (timing and approach vary by clinician and case).

Relevant hip anatomy

Key structures involved include:

Femoral head: the “ball” of the ball-and-socket hip joint
Femoral neck: the narrow bridge of bone connecting the head to the femoral shaft
Acetabulum: the “socket” in the pelvis
Joint capsule: a fibrous envelope around the hip joint; femoral neck fractures within the capsule are called intracapsular
Retinacular vessels / blood supply to the femoral head: small vessels that can be affected by fracture displacement, contributing to concern for femoral head ischemia (reduced blood flow)

Onset, duration, reversibility

Garden IV is not a medication or device, so “onset and duration” do not apply. The closest relevant concept is reducibility and stability:

The displacement may be partially correctable with reduction (realignment), but the injury itself does not “wear off.”
Stability after reduction depends on fracture pattern, bone quality, and the method of fixation or replacement chosen. Varies by clinician and case.

Garden IV Procedure overview (How it’s applied)

Garden IV is not a procedure; it is a radiographic and clinical classification applied during evaluation of a suspected femoral neck fracture. A typical high-level workflow looks like this:

Evaluation / exam – History (fall or trauma, sudden hip/groin pain, inability to walk) – Physical exam (leg position, pain with movement, neurovascular checks)
Preparation – Pain control and safe positioning for imaging – Assessment of medical stability and comorbidities that may affect planning
Intervention / testing – Imaging: usually plain X-rays of the pelvis and hip – Garden classification is assigned based on alignment and displacement seen on imaging – Additional imaging (such as CT or MRI) may be used when the diagnosis is uncertain or to clarify details. Varies by clinician and case.
Immediate checks – Documentation of fracture type (e.g., displaced intracapsular femoral neck fracture, Garden IV) – Discussion among care teams regarding surgical versus non-surgical pathways, taking into account patient factors and fracture features
Follow-up – Post-treatment imaging and functional follow-up are used to monitor healing or implant status, depending on the management approach

This overview is informational; specific pathways depend on local protocols and individual clinical factors.

Types / variations

Garden IV sits within a broader framework and is often discussed alongside related variations.

Garden classification (context)

Garden I: incomplete or valgus-impacted fracture (generally nondisplaced/impacted)
Garden II: complete fracture without displacement
Garden III: complete fracture with partial displacement
Garden IV: complete fracture with full displacement and no continuity

Variations within “Garden IV” descriptions

Even among Garden IV fractures, clinicians may further describe:

Degree and direction of displacement (how far and in what direction the fragments have shifted)
Comminution (whether the fracture has multiple fragments), which can affect stability
Associated injuries (acetabular injury, pelvic fractures, soft-tissue injury), especially in high-energy trauma
Bone quality considerations (e.g., osteoporotic bone), which may influence fixation choices

Related classification and descriptive tools

Garden IV is often complemented by:

Pauwels classification (focuses on fracture line angle and shear vs compression forces)
Descriptions of intracapsular vs extracapsular location (critical for blood supply considerations)
Surgical descriptors (fixation vs arthroplasty) used for operative reporting rather than fracture staging

Pros and cons

Pros:

Provides a widely recognized shorthand for a displaced intracapsular femoral neck fracture.
Helps standardize communication across emergency, radiology, orthopedic, and rehab teams.
Supports triage and planning, since displacement often changes management considerations.
Encourages attention to complication risk factors that correlate with displacement.
Useful for documentation and research grouping of similar fracture severity.

Cons:

Interobserver variability can occur, especially between adjacent categories.
Does not fully describe fracture angle, comminution, or bone quality, which may affect stability and planning.
A single label may oversimplify complex injury patterns in high-energy trauma.
Classification is imaging-dependent and can be limited by positioning or image quality.
It does not by itself determine the “right” treatment; patient factors remain central. Varies by clinician and case.

Aftercare & longevity

Because Garden IV is a classification rather than a treatment, “aftercare” relates to what typically follows a displaced femoral neck fracture and whichever management approach is used (fixation, partial replacement, total replacement, or nonoperative care in selected situations).

Factors that commonly influence recovery course and longer-term outcomes include:

Severity of displacement and fracture pattern, including comminution
Time from injury to definitive management, which may affect planning and complication risk; timing decisions vary by clinician and case
Chosen treatment strategy
Internal fixation outcomes can depend on bone quality and stability achieved
Arthroplasty outcomes can depend on implant choice, fixation method, and soft-tissue status (varies by material and manufacturer)
Weight-bearing status and rehabilitation plan
These are individualized and can differ depending on fixation stability, surgical technique, and surgeon preference
Medical comorbidities
Conditions affecting healing and recovery (e.g., osteoporosis, diabetes, smoking status, nutritional status) can influence the overall course
Follow-up adherence
Imaging and functional checks help monitor healing or implant position and detect complications early
Baseline function and support system
Pre-injury mobility level and available help at home often affect discharge planning and rehab needs

Longevity, in practical terms, may refer to how durable healing is after fixation or how long an implant performs after arthroplasty. These outcomes vary widely by patient factors, implant design, surgical technique, and rehabilitation.

Alternatives / comparisons

Garden IV is one way to describe a femoral neck fracture; alternatives and comparisons fall into two broad categories: alternative classifications and alternative management pathways.

Classification comparisons

Garden vs Pauwels
Garden emphasizes displacement.
Pauwels emphasizes fracture line angle and mechanical forces (shear vs compression), which can influence fixation strategy.
Descriptive radiology vs staged classification
Some clinicians prefer detailed narrative reports (direction of displacement, comminution, impaction) alongside or instead of a single stage.
CT/MRI vs X-ray
X-ray is commonly the first test.
CT can better show bony detail and complex patterns.
MRI is often used when a fracture is suspected but not visible on X-ray (occult fracture). Use varies by clinician and case.

Management comparisons for displaced femoral neck fractures (high level)

Observation / nonoperative care
Generally reserved for selected cases (for example, certain non-ambulatory patients or those with major surgical contraindications). Suitability varies by clinician and case.
Internal fixation (pins/screws or a sliding hip screw)
Often considered when preserving the native femoral head is a priority, depending on age, activity level, and fracture features.
May carry concerns about healing and blood supply in displaced intracapsular fractures.
Hemiarthroplasty (partial hip replacement)
Replaces the femoral head while leaving the acetabulum intact.
Commonly discussed in older patients with displaced fractures, depending on function and joint status.
Total hip arthroplasty (total hip replacement)
Replaces both femoral head and acetabulum.
Often considered when there is pre-existing arthritis or higher functional demand, but candidacy varies widely.

Each option has trade-offs involving stability, recovery expectations, complication profiles, and long-term function. The “best” approach depends on individual anatomy, goals, and health status.

Garden IV Common questions (FAQ)

Q: What does Garden IV mean in plain language?
It means a femoral neck fracture where the broken parts are fully displaced and no longer line up normally. In simple terms, the “ball” and “neck” of the hip are no longer aligned. It is a severity label used on imaging and in orthopedic notes.

Q: Is Garden IV the same thing as a hip fracture?
Garden IV is a type of hip fracture, specifically a displaced fracture of the femoral neck inside the joint capsule. “Hip fracture” is a broad term that can also include intertrochanteric and subtrochanteric fractures. Those other fracture types are classified differently.

Q: Does Garden IV always require surgery?
Garden IV commonly leads to surgical discussions because the fracture is displaced and unstable. However, whether surgery is appropriate depends on overall health, mobility goals, and medical risk factors. Varies by clinician and case.

Q: Why is displacement such a concern in femoral neck fractures?
Displacement changes the biomechanics of the hip and can make the fracture unstable. It can also increase concern about the blood supply to the femoral head, which is relevant to healing and longer-term joint function. Risk levels and implications vary by patient and fracture pattern.

Q: How painful is a Garden IV fracture?
Pain levels vary, but displaced hip fractures are often very painful, especially with movement or attempts to stand. Some people, particularly older adults, may describe more groin pain than “hip” pain. Pain experience is influenced by individual factors and any medications already being used.

Q: How is Garden IV diagnosed?
It is typically diagnosed using a combination of physical exam findings and imaging, most often plain X-rays of the pelvis and hip. If the X-ray is unclear or the pattern needs more detail, additional imaging may be used. The final classification can depend on image quality and reader interpretation.

Q: What is the recovery timeline for a Garden IV fracture?
Recovery depends on the treatment approach (fixation vs replacement vs nonoperative care), overall health, and rehabilitation progress. Many people require a period of assisted mobility and structured rehab. Specific milestones vary by clinician and case.

Q: Will I be allowed to put weight on the leg after treatment?
Weight-bearing instructions depend on the stability of the repair or the type of arthroplasty performed, plus surgeon preference and patient factors. Some protocols allow earlier weight bearing than others. Only the treating team can define the appropriate level for a specific case.

Q: When can someone return to driving or work after a Garden IV hip fracture?
This varies based on which side was injured, pain control, mobility, reaction time, and the type of treatment performed. Work demands (desk vs physical job) also matter. Clearance timing varies by clinician and case.

Q: How much does treatment typically cost?
Costs can vary widely based on region, hospital setting, insurance coverage, imaging needs, length of stay, rehabilitation services, and whether fixation or arthroplasty is used. Implant-related costs can vary by material and manufacturer. A care team or billing department typically provides the most accurate estimates for a specific situation.