134 patients with high-energy Pauwels type III femoral neck fractures were randomized to receive either compressive buttress screw (CBS) fixation (n=67) or off-axial partial threaded cannulated screw (OPTCS) fixation (n=67). The primary outcome of interest was complication rates, including fixation failure, fracture nonunion, and avascular necrosis of the femoral head (ANFH) at 24 months. Secondary outcomes of interest included fixation loosening, femoral neck shortening and varus collapse, patient function using the Harris hip score (HHS), and quality of life using the EuroQol-5D-5L (EQ-5D) questionnaire. Outcomes were assessed at 24 months. Overall, the results of the study revealed that CBS fixation significantly reduced the rates of fixation failure and fracture nonunion compared to OPTCS fixation. The CBS group also demonstrated better functional outcomes and quality of life scores. These findings suggest that CBS fixation is more effective in reducing complications and improving functional outcomes in young adults with vertical femoral neck fractures.