Objective To explore the curative effect of internal fixation with 4 cannulated screws in the treatment of femoral neck fracture of Pauwels Ⅲ. Methods From January 2014 to November 2018, 70 patients with fresh Pauwels type Ⅲ femoral neck fracture were retrospectively studied in our department. They were divided into two groups randomly. 35 patients were treated with 4 cannulated screws internal fixation (4 screws group) and 35 patients were treated with 3 cannulated screws internal fixation (3-screw group). The perioperative and follow-up documents were compared between the two groups. In addition, the patient’s satisfaction and clinical results grade based on Harris score were used for assessment of outcomes. Results The operative time, intraoperative blood loss and incision length of the 4-nail group were significantly higher than those of the 3-nail group, with statistically significant differences (P<0.05). However, there were statistically significant differences between the 4-nail group in the total load time, femoral neck shortening, screw withdrawal, neck shaft angle, fracture healing time and Harris score (P<0.05).There was no significant difference in fracture nonunion and femoral head necrosis between the two groups (P> 0.05). Conclusion Compared with 3 cannulated screws, 4 cannulated screws can reduce the fracture nonunion and the failure of early internal fixation in the treatment of femoral neck fracture, and have a stronger anti-shear force effect.