OBJECTIVE To compare the effectiveness of the femoral neck system (FNS) and inverted triangle cannulated screws (ITCS) for the treatment of Pauwels type Ⅲ femoral neck fractures. METHODS The clinical data of 59 patients with Pauwels type Ⅲ femoral neck fractures treated between May 2019 and November 2020 were retrospectively analysed. The patients were divided into FNS group (28 cases) and ITCS group (31 cases) according to the different internal fixation. There was no significant difference in gender, age, affected side, body mass index, cause of injury, smoking history, alcohol abuse history, Pauwels angle, Garden classification, AO/Orthopaedic Trauma Association (AO/OTA) classification, and time from injury to operation between the two groups ( P>0.05). The operation time, incision length, intraoperative blood loss, extra assisted reduction procedures (Kirschner wire prying reduction or open reduction), hospitalization stay, and early complications were recorded and compared between the two groups. Garden index and Haidukewych score were used to evaluate fracture reduction. Fracture healing time, lateral thigh irritation, time of partial or total weight-bearing postoperatively, shortening length and degree of femoral neck, change of caput-collum-diaphysis (CCD) angle (the difference of CCD angle between immediate after operation and last follow-up), incidence of osteonecrosis of femoral head and revision surgery were recorded and compared between the two groups. Hip joint function were evaluated by Harris score. RESULTS The operation time of FNS group was significantly shorter than ITCS group, and the incision length was significantly longer than ITCS group ( P<0.05). There was no significant difference in intraoperative blood loss, assisted reduction, Garden index, Haidukewych score, and hospitalization stay between the two groups ( P>0.05). All the incisions healed by first intention. There were 2 deep vein thrombosis in the FNS group and 1 pulmonary infection and 1 deep vein thrombosis in the ITCS group. No significant difference was found in the incidence of early postoperative complications (7.1% vs. 6.5%) between the two groups ( P=1.000). Patients in both groups were followed up 3-14 months, and there was no significant difference in follow-up time between the two groups ( t=-0.553, P=0.582). The fracture healing time, Harris score, and the partial weight-bearing time after operation of the FNS group were significantly better than those of the ITCS group ( P<0.05). However, there was no significant difference in total weight-bearing time between the two groups ( Z=-1.298, P=0.194). No lateral thigh irritation was found in the FNS group, while 10 patients in the ITCS group had lateral thigh irritation, and the incidence between the two groups (0 vs. 32.3%) was significant ( P=0.001). At last follow-up, the shortening length and degree of femoral neck and the change of CCD angle in FNS group were significantly less than those in ITCS group ( P<0.05). There was no patient with osteonecrosis of femoral head or reoperation in the FNS group, while 4 patients in the ITCS group underwent reoperation (including 2 cases of osteonecrosis of the femoral head). However, the incidences (0 vs. 6.5%; 0 vs.12.9%) between the two groups were not significant ( P=0.493; P=0.114). CONCLUSIONS Using FNS to treat Pauwels type Ⅲ femoral neck fracture is simple as well as able to reduce the shortening of the femoral neck and the change of the CCD angle. Also, FNS is conducive to the recovery of hip joint function, which should be considered as a new choice for the treatment of young femoral neck fracture patients.