Trauma X-ray - Lower limb

Hip fracture

Fractures of the proximal femur or 'hip' are a common clinical occurrence in elderly, osteoporotic patients.

Many hip fractures are clinically and radiologically obvious. Others are more difficult to diagnose. It is important to be aware that the common clinical signs of a shortened and externally rotated leg may be absent if the fracture is not displaced. In this case the X-ray may not show an obvious fracture. Repeat X-rays, CT or MRI may be required if pain persists.

Particular care is needed in assessing the X-ray when physical examination is limited, for example if a patient is acutely confused.

Standard views

AP (Anterior-Posterior) pelvis and Lateral hip. The AP of the whole pelvis (not shown on the X-rays on this page) should be fully assessed because pelvic fractures can mimic the clinical features of a hip fracture.

Key points

  • Not all hip fractures are visible on the initial X-ray and follow-up imaging may be required if concern remains
  • Particular caution is required in the case of acutely confused patients
  • Remember to assess the surrounding pelvic bones
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Hip X-ray anatomy - Normal AP

  • Shenton's line is formed by the medial edge of the femoral neck and the inferior edge of the superior pubic ramus
  • Loss of contour of Shenton's line is a sign of a fractured neck of femur
  • IMPORTANT NOTE: Fractures of the femoral neck do not always cause loss of Shenton's line
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Hip X-ray anatomy - Normal Lateral

  • The cortex of the proximal femur is intact
  • The Lateral view is often not so clear because those with hip pain find the positioning required difficult

Fracture classification

Proximal femoral fractures either involve bone which is enveloped by the ligamentous hip joint capsule (intracapsular), or involve bone below the capsule (extracapsular).

Intracapsular fractures

Intracapsular fractures include subcapital (below the femoral head), transcervical (across the mid-femoral neck), or basicervical (across the base of the femoral neck). These injuries may be correctly termed fractures of the 'neck of femur' (NOF).

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Intracapsular v extracapsular

  • The capsule envelopes the femoral head and neck
  • Subcapital, transcervical and basicervical fractures are intracapsular hip injuries
  • Intertrochanteric and subtrochanteric fractures do not involve the neck of femur
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Intracapsular fracture - Subcapital -AP

  • (Same case as below)
  • Shenton's line is disrupted
  • Increased density of the femoral neck is due to overlapping - impacted bone
  • The lesser trochanter is more prominent than usual - due to external rotation of the femur
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Intracapsular fracture - Subcapital - Lateral

  • (Same case as above)
  • Loss of integrity of cortical bone indicates fracture
  • Trabecular bone of the femoral neck overlaps

Intracapsular fracture severity - Garden classification

The Garden classification system is a traditional means of assessing severity of neck of femur fractures. The system broadly corresponds with prognosis - the more displaced, the more likely the blood supply to the femoral head is compromised. In reality the distinction between the classes can be difficult.

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Garden classification - Simulation

  • I - Incomplete or impacted bone injury with valgus angulation of the distal component
  • II - Complete (across whole neck) - undisplaced
  • III - Complete - partially displaced
  • IV - Complete - totally displaced
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Garden IV fracture

  • Loss of Shenton's line
  • Complete fracture of the full diameter of the femoral neck
  • Total displacement of the 2 fracture components

Extracapsular fractures

Extracapsular fractures of the proximal femur include intertrochanteric (between the trochanters) and subtrochanteric (distal to the trochanters). These fractures do not involve the neck of the femur.

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Intertrochanteric fracture

  • A fracture line runs between the trochanters
  • There is comminution with separation of the lesser trochanter
  • Note the fracture does not involve the femoral neck
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Subtrochanteric fracture

  • This fracture passes distal to the trochanters
  • The femoral neck remains intact

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