ObjectiveTo elucidate the therapeutic challenges and recent advances in managing Garden type Ⅳ femoral neck fractures in young adults through the perspective of anatomical blood supply, identifying current limitations and proposing future research directions for optimizing clinical treatment strategies. Methods A comprehensive review of recent domestic and international literature on Garden type Ⅳ femoral neck fractures in young adults was conducted, focusing on the anatomical basis of femoral neck vascularization, innovations in internal fixation techniques, vascular reconstruction methods, and applications of adjunct technologies. ResultsThe treatment of Garden type Ⅳ femoral neck fractures in young adults has evolved from internal fixation toward an integrated biomechanical and biological approach. The distinct anatomy of the femoral neck and the vulnerability of femoral head perfusion render the management of Garden type Ⅳ fractures particularly challenging in young adults. Enhanced internal fixation systems have significantly improved stability through optimized biomechanical configurations. Vascularized (or muscle-pedicle) bone grafting offers an effective biological reconstruction strategy for high-risk patients. Conclusion Individualized comprehensive treatment, grounded in the understanding of femoral neck vascular anatomy, is crucial for improving outcomes. Future efforts should integrate intelligent surgical planning and biological therapeutics to further enhance therapeutic efficacy.