CHAPTER 9

The Hip

Proximal femoral epiphyseal separation rare

Hip Checklists      
Slipped capital femoral epiphysis (SCFE)
1. Radiographic examination
Hip 4. Injuries likely to be missed
AP pelvis Low-impact trauma – elderly
AP hip Fine, subtle fractures
Frog leg-view hip Femoral neck
Groin lateral hip Intertrochanteric
Femur High-impact trauma – all ages
AP hip Proximal injuries of the hip in association with femoral
AP femoral shaft and condyles shaft fractures
Lateral femoral shaft and condyles Posterior dislocation of hip
Oblique femoral shaft Fracture of acetabulum
Fracture of femoral neck
2. Common sites of injury in adults
5. Where else to look when you see
Elderly – low-impact trauma (fall from standing height)
Femoral neck something obvious
Intertrochanteric Obvious Look for
Greater trochanter
Pelvic fractures presenting as hip fractures Fracture of femoral shaft Posterior dislocation of hip
Pubic rami Fracture of acetabulum
Iliac wing Fracture of femoral neck
Adult – R/O pathologic fracture Fracture of distal femur (condyles)
Basicervical fractures Fracture of patella
Lesser trochanteric avulsions Fracture of greater Intertrochanteric extension (MRI)
Transverse subtrochanteric fractures ­trochanter
Adult – high-impact trauma (MVC)
Posterior hip dislocation
Femoral neck
6. Where to look when you see
Subtrochanteric
Femoral shaft nothing at all
Search for alternative diagnoses, fractures of
Iliac crest
3. H
 ip fractures rare in children
Pubic rami
and adolescents Acetabulum
Pelvic fractures about hip common Greater trochanter of proximal femur
Pubic rami Need to rule out obscure/not apparent femoral neck or
Iliac wing intertrochanteric fracture
Occasional If questionable radiographic findings noted – CT often
Femoral neck sufficient
Posterior dislocation If x-rays negative – MRI required

172

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 The Hip     173

Hip – The Primer       AP femoral shaft and condyles

Lateral femoral shaft and condyles
Oblique femoral shaft
1. Radiographic examination
Hip A radiographic examination of the traumatized hip should
AP pelvis include the four standard views listed above. An AP of the
AP hip pelvis (Fig. 9-1A) is included to survey the surrounding bony
Frog leg-view hip pelvis for fractures (i.e., pubic rami and iliac wings), which can
Groin lateral hip mimic hip fractures. The AP view of the hip (Fig. 9-1B) should
Femur be obtained with the hip in internal rotation to place the femo-
AP hip ral head and neck in profile. If the patient’s foot is in external

B C

Anterior

Acetabulum
Head
Intertrochanteric crest

150°
Neck
Shaft
Lesser trochanter

Ischial
spine Ischial
tuberosity E
Greater trochanter

D Posterior
FIGURE 9-1  Radiographic view of the traumatized hip: An AP of the pelvis (A) showing the surrounding bony pelvis for fractures that can
mimic hip fractures; an AP view of the hip (B) in internal rotation to place the femoral head and neck in profile; the frog-leg view (C) with leg
abducted and externally rotated results in a modified lateral view of the proximal femur. The groin lateral (D, E) is an optional view of the
­femoral head and neck that better demonstrates posterior rotation of the femoral head in the presence of subcapital fractures.

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174      The Hip

A B C
FIGURE 9-2  AP view showing slight internal rotation of the hip (A) best profiles the head and neck junction to identify femoral neck and
­intertrochanteric femur fractures. A displaced fracture of the femoral neck showing the distal fragment in external rotation with the femur drawn
proximally (B). External rotation of the hip on the AP view without a femoral neck fracture is a common occurrence (C).

Subcapital fractures, particularly nondisplaced fractures,

are obscured and readily overlooked (Fig. 9-3A) with external
rotation. A repeat PA view should be obtained with slight inter-
nal rotation of the femur (Fig. 9-3B). Note that an impacted
subcapital fracture is now visible. An even more striking exam-
ple of difficulty in seeing fractures on the AP view with external
rotation is shown in Fig. 9-4. On the initial AP view with exter-
nal rotation no fracture is seen or even suspected (Fig. 9-4A).
However, the repeat, properly positioned AP view clearly
depicts a widely separated fracture of the greater tuberosity
(Fig. 9-4B) that is not apparent on the initial examination.

2. Common sites of injury in adults

A B
Elderly – low-impact trauma (fall from standing height)
FIGURE 9-3  With external rotation, subcapital fractures, particularly Femoral neck
nondisplaced, are obscured and can easily be overlooked (A). In a Intertrochanteric
repeat PA view, there is a slight internal rotation of the femur with
Greater trochanter
subcapital fracture now visible (B).
Pelvic fractures presenting as hip fractures
Pubic rami
rotation and he or she is unable to rotate the foot, the AP view Body of the pubis
should be taken as the patient lies, because with displaced frac- Iliac wing
tures of the femoral neck the hip is typically held in external Adult – R/O pathologic fracture
rotation. If this view shows no evidence of hip fracture, the Basicervical fractures
toes should be brought together by wrapping the forefeet in a Lesser trochanteric avulsions
towel to place the hip in internal rotation, and a repeat AP view Transverse subtrochanteric fractures
should be obtained. The frog leg-view (Fig. 9-1C) is obtained Adult – high-impact trauma (MVC)
with leg abducted and externally rotated, in effect, resulting Posterior hip dislocation
in a modified lateral view of the proximal femur. The groin Femoral neck
lateral (Figs. 9-1D and 9-1E) is an optional view of the femoral Femoral shaft
head and neck that better demonstrates posterior rotation of
the femoral head in the presence of subcapital fractures. Pattern of search. A diagram of the hip (Fig. 9-5A)
The AP view with slight internal rotation of the hip (Fig. pinpoints the common sites of fracture in adults as identified
9-2A) best profiles the head and neck junction, which facilitates by red lines. Your pattern of search should include all sites:
identification of fractures of the femoral neck and intertrochan- subcapital, intertrochanteric, and greater trochanteric.
teric femur. With a displaced fracture of the femoral neck the Fractures of the hip are most commonly encountered in
distal fragment lies in external rotation, and the femur is drawn the elderly in association with generalized osteoporosis. They
proximally (Fig. 9-2B). External rotation of the hip on the AP occur in low-impact trauma, usually a fall from a standing
view in the absence of a femoral neck fracture is, unfortunately, height. The most common is a subcapital fracture of the femo-
a common occurrence (Fig. 9-2C). External rotation of the hip ral neck. Displaced subcapital fractures are held in external
foreshortens the femoral neck, and the underlying greater tro- rotation, and the femoral shaft is drawn proximal, shorten-
chanter obscures the femoral head and neck junction. Fractures ing the femur (Fig. 9-5B). The groin lateral view (Fig. 9-5C)
of the femoral neck are difficult to identify on such views. shows the posterior rotation and displacement of the femoral

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A B
C D
head. Follow the anterior cortex of the femur to the fracture.
Displaced fractures of the femoral neck result in devascular-
ization of the femoral head, and therefore a hemiarthroplasty
(Fig. 9-5D) is required.
Subcapital fractures.  Most subcapital fractures are impacted;
two cases are shown (Figs. 9-6A and 9-6B-E). The head
fragment is usually rolled posterolateral, valgus (Figs. 9-6A and
9-6B), or, less commonly, posteromedial, varus (see Fig. 9-7)
and impacted on the femoral neck. Disruption of the medial
cortex of the femoral neck (Fig. 9-6A) is variable and often not
apparent (Fig. 9-6B). CT confirms the diagnosis in questionable
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The Hip     175
FIGURE 9-4  AP view example that demonstrates difficulty
in seeing fractures with external rotation shown (A). On the
initial AP view with external rotation no fracture is seen or
even suspected. A properly positioned AP view depicts a
widely separated fracture of the greater tuberosity (B) that is
not apparent on the initial examination.
FIGURE 9-5  A diagram of the hip (A) with redlines
pinpointing the common sites of fracture in adults.
Displaced subcapital fractures are held in external
rotation, and the femoral shaft is drawn proximal,
shortening the femur (B). The groin lateral view (C)
shows the posterior rotation and displacement of
the femoral head. A hemiarthroplasty is required for
displaced fractures of the femoral neck that result in
devascularization of the femoral head (D).
cases (Fig. 9-6C, coronal reconstruction, and Fig. 9-6D, axial).
Impacted fractures are treated by screw fixation (Fig. 9-6E)
because the majority of the blood supply to the femoral head
remains intact and therefore the head is viable.
The diagnosis of varus-impacted subcapital fractures can
pose problems. The femoral head is rolled posteromedial (Fig.
9-7A), and the medial impaction of the femoral head and
neck (Fig. 9-7B) can be misinterpreted as an osteophytic spur
in keeping with osteoarthritis (OA). However, the absence
of spur formation and joint space narrowing superiorly and
laterally should make the diagnosis of OA much less tenable.
CT may be required to resolve the confusion and establish
176      The Hip

the diagnosis of a subcapital fracture with a varus deformity
(Figs. 9-7C, axial, and 9-7D, coronal reconstruction). Note the
fracture of the femoral neck on the upper outer cortex, medial
impaction of the femoral head and neck, and medial and pos-
terior rotation of the femoral head.
Garden classification of femoral neck fractures. This
classification consists of four stages (Fig. 9-8): Stage 1,
nondisplaced, incomplete fracture with or without slight
impaction; Stage 2, nondisplaced, complete fracture usually
with some degree of impaction; Stage 3, complete fracture
with partial displacement, fracture surfaces in apposition
posteriorly and inferiorly; Stage 4, complete fracture, fully
displaced without contact between fracture surfaces. In Stages
3 and 4 the proximal fragment is drawn proximally and
externally rotated.
The classification is simple, widely used, and predictive of
subsequent avascular necrosis of the femoral head. In Stages
1 and 2 the blood supply to the femoral head is largely pre-
served. Stages 1 and 2 are treated by pin fixation and fixed with
multiple (commonly, three) intramedullary screws. In Stages
3 and 4 the blood supply is disrupted. The femoral head frag-
ment is therefore excised, and a unipolar metallic arthroplasty
is performed.

A B C

FIGURE 9-6  Subcapital fractures.

Two cases are shown: The head frag-
ment is usually rolled posterolateral,
valgus (A, B), and impacted on the
femoral neck. Disruption of the medial
cortex of the femoral neck (A) is vari-
able and often not apparent (B). CT
confirms the diagnosis in question-
able cases (C, coronal reconstruction,
and D, axial). Impacted fractures are
treated by screw fixation (E) because
the majority of the blood supply to
the femoral head remains intact and D E
therefore the head is viable.

A B C D
FIGURE 9-7 (A) The femoral head is rolled posteromedial, and the medial impaction of the femoral head and neck (B) is sometimes misinter-
preted as an osteophytic spur in keeping with osteoarthritis (OA). (C) CT can be used to establish the diagnosis of a subcapital fracture with a
varus deformity (C, axial, and D, coronal reconstruction). Note the fracture of the femoral neck on the upper outer cortex, medial impaction of
the femoral head and neck, and medial and posterior rotation of the femoral head.

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 The Hip     177

Intertrochanteric fractures.  Intertrochanteric fractures may

contain two (Fig. 9-9A), three (Fig. 9-9B), or four fragments
(Fig. 9-9C); the third and fourth contain the lesser and greater
trochanters. These fractures are usually readily identified on
standard radiographs.
On the other hand, nondisplaced intertrochanteric fractures
may pose a problem. They manifest by a fine, linear fracture
line (Figs. 9-10A and 9-10B).
Such lines may be only partially visualized without obvious
cortical disruption. A simple repeat examination will often
Normal Stage I Stage II
reveal the presence of a fracture more convincingly. Be suspi-
cious of any oblique linear lucency in the base of the femoral
neck or intertrochanteric portion of the femur. The disruption
of the medial cortex in an intertrochanteric fracture occurs in
the area of the lesser trochanter (Fig. 9-10B). Examine this area
closely. The intact, normal cortex of a right femur is shown for
comparison (Fig. 9-10C).

Pathologic fractures. Don’t overlook the possibility of

Stage III Stage IV
FIGURE 9-8  Garden classification of femoral neck fractures. Stage 1:
Nondisplaced, incomplete fracture with or without slight impaction.
Stage 2: Nondisplaced, complete fracture usually with some degree
of impaction. Stage 3: Complete fracture with partial displacement.
Fracture surfaces in apposition posteriorly and inferiorly. Stage 4:
Complete fracture, fully displaced without contact between fracture
surfaces. In Stages 3 and 4 the proximal fragment is drawn proximally
and externally rotated.
pathologic fracture. There are three specific sites of fracture
(Fig. 9-11A) associated with osseous metastatic foci:
basicervical fractures of the femoral neck (Fig. 9-11B, CA
lung), lesser trochanteric avulsions (Fig. 9-11C, CA breast),
and transverse subtrochanteric fractures (Fig. 9-11D, CA
prostate). Fractures at these sites are pathologic until proven
otherwise. Look for signs of bone destruction when fractures
are seen in these locations.

A B C
FIGURE 9-9  Intertrochanteric fractures showing two (A), three (B), or four fragments (C), with the third and fourth showing the lesser and
greater trochanters. These fractures are usually readily identified on standard radiographs.

FIGURE 9-10  Nondisplaced intertrochanteric fractures mani-

A B
fest by a fine, linear fracture line that may be only partially
visualized (A, B). The disruption of the medial cortex in an
intertrochanteric fracture occurs in the area of the lesser tro-
C chanter (B). The intact, normal cortex of a right femur is shown
for comparison (C).

D o w n l o a d e d f r o m C l i n i c a l K e y . c o m a t C l
F o r p e r s o n a l u s e o n l y . N o o t h e r u s e s w i t h o u
178      The Hip
A B
FIGURE 9-11  Pathologic fractures. There are three
specific sites of fracture (A) associated with osseous
metastatic foci: basicervical fractures of the femoral
neck (B, CA lung), lesser trochanteric avulsions
(C, CA breast), and transverse subtrochanteric frac-
tures (D, CA prostate). Fractures at these sites are
pathologic until proven otherwise. Look for signs of
bone destruction when fractures are seen in these
locations.
Stress and insufficiency fractures.  Stress and insufficiency
fractures are similar in location: subcapital and basicervical
(Fig. 9-12). Their imaging characteristics are also similar.
They differ only in the age of the patient and undergoing
activity at the time of the injury. Stress fractures occur in the
athlete and athletically inclined in the presence of normal
bone mineral density as a result of their athletic pursuits;
insufficiency fractures occur in the osteopenic elderly and
infirm in the course of their normal daily routine. Athletes and
the elderly complaining of hip pain with negative radiographic
examinations of the hip should have an MRI to identify or
exclude subcapital (Figs. 9-12A and 9-12B) or basicervical
stress and insufficiency fractures of the femoral neck. The
AP view (Fig. 9-12B) reveals no evidence of fracture. The
Cor Stir MRI (Fig. 9-12C) clearly demonstrates a subcapital,
low-signal serpiginous fracture line surrounded by edema
and hemorrhage. Failing to obtain an MRI may allow the
fracture to progress to a complete fracture like this basicervical
fracture (Fig. 9-12D) sustained while walking. The patient had
disseminated sarcoidosis and was severely osteopenic from
long-term steroid administration.
A unique form of insufficiency fracture of the femoral shaft
(Figs. 9-12A, 9-13A, and 9-13B) is associated with long-term
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C D
bisphosphonate administration. The fracture occurs in the
lateral cortex of the femoral shaft, more commonly proximal.
The thickened cortex is fusiform, with the fracture line appearing
as a horizontal lucency located centrally (Fig. 9-13A), better
seen in the cropped figure (Fig. 9-13B). The lesions are fre-
quently bilateral. Always radiograph the opposite side when
such a lesion is identified. These patients often present with a
complete fracture of the femoral shaft.
Posterior dislocations. Posterior fracture dislocations of
the hip are particularly common in high-impact trauma. The
head of the femur is typically displaced out of the acetabulum
superiorly and posteriorly (Figs. 9-14A-C), and the femoral
shaft is characteristically adducted (Figs. 9-14A and 9-14C).
Displaced fractures of the posterior rim of the acetabulum
are frequent (Figs. 9-14A-C), better seen and more easily
appreciated on the internal oblique view (Fig. 9-14C).
Entrapment of bone fragments within the joint frequently
occurs following reduction of a hip dislocation. These must
be recognized and surgically removed. A posterior disloca-
tion of the hip is shown (Fig. 9-15A). No bony fragments are
seen within the joint. On the postreduction radiograph (Fig.
9-15B), however, the left hip joint space is widened compared

A B
C D
A B
FIGURE 9-13  A unique form of insufficiency fracture of the femoral
shaft is associated with long-term bisphosphonate administration.
The thickened cortex is fusiform with the fracture line appearing as
a horizontal lucency located centrally (A), better seen in the cropped
figure (B).
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The Hip     179
FIGURE 9-12  Stress and insufficiency fractures.
Stress and insufficiency fractures are similar in loca-
tion: subcapital and basicervical (A). The AP view
(B) reveals no evidence of fracture. The Cor Stir MRI
(C) clearly demonstrates a subcapital, low-signal
serpiginous fracture line surrounded by edema and
hemorrhage. Failing to obtain an MRI may allow
the fracture to progress to a complete fracture like
this basicervical fracture (D) sustained while walk-
ing. This patient had disseminated sarcoidosis and
was severely osteopenic from long-term steroid
administration.
to the opposite side. This indicates entrapped bone or cartilage
fragments within the joint. Hip joint widening should not be
attributed to a simple joint effusion. An entrapped fragment is
confirmed by a subsequent CT scan (Fig. 9-15C).
CT may be performed prior to or after or both prior to
and after reduction of a posterior dislocation. The important
features to note are the dislocation, the presence or absence of
fractures of the posterior rim of the acetabulum, fractures of
the femoral head, and bone fragments within the joint. This
AP view of the hip (Fig. 9-16A) shows the classic features of
a posterior dislocation: adduction of the femur, superior dis-
placement of the femoral head out of the acetabulum, frag-
ment from the rim of the acetabulum lying just lateral to the
femoral head, and small bone fragments projected medial to
the inferior aspect of the femoral head, likely within the joint.
Prior to reduction (Figs. 9-16B and 9-16C), axial CT (Fig.
9-16B) demonstrates the posterior dislocation and fracture
of the posterior rim of the acetabulum. Bone fragments are
seen with the joint. Sagittal reconstruction CT (Fig. 9-16C)
again shows posterior dislocation. Note impaction of femoral
head against the fracture’s rim of the acetabulum. Following
180      The Hip

A B C

FIGURE 9-14  Posterior dislocations.  Posterior fracture dislocations of the hip are particularly common in high-impact trauma. The head of
the femur is typically displaced out of the acetabulum superiorly and posteriorly (A-C), and the femoral shaft is characteristically adducted
(A,C). Displaced fractures of the posterior rim of the acetabulum are frequent, better seen, and more easily appreciated on the internal oblique
view (C).

A B C
FIGURE 9-15  A posterior dislocation of the hip is shown (A). No bony fragments are seen within the joint. On the postreduction radiograph
(B), however, the left hip joint space is widened compared to the opposite side. An entrapped fragment is confirmed by a subsequent CT scan (C).

A B C
FIGURE 9-16  This AP view of the hip (A) shows the
classic features of a posterior dislocation: adduction
of the femur, superior displacement of the femoral
head out of the acetabulum, fragment from the rim
of the acetabulum lying just lateral to the femoral
head, and small bone fragments projected medial
to the inferior aspect of the femoral head, likely
within the joint. CT prior to reduction (B, C). Axial
CT (B) demonstrates the posterior dislocation and
fracture of the posterior rim of the acetabulum.
Sagittal reconstruction CT (C) again shows posterior
dislocation. Following reduction (D, E) the axial view
(D) shows bone fragments entrapped within the
joint and large fracture of the posterior rim of the D E
acetabulum.

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 The Hip     181

A B

C D
FIGURE 9-17  Proximal femur fractures. Variability of fractures in high impact trauma (A). The fracture in the femoral neck is often vertical,
diagonal across the femoral neck (B), or involves the basicervical portion of the neck (C, D). The fracture may involve both femoral neck and
intertrochanteric region. It may be comminuted. CT clarifies the nature of the fracture (D).

reduction (Figs. 9-16D and 9-16E), the axial view (Fig. 9-16D)
shows bone fragments entrapped with the joint and large frac-
ture of the posterior rim of the acetabulum. A slightly lower
axial view (Fig. 9-16E) reveals an impaction fracture of the
head of the femur between 11 and 2 o’clock on the anterior
surface of the femoral head. This is the characteristic location
of femoral head fractures sustained in posterior dislocations
of the hip; the anterior surface of the head is impacted against
the acetabular rim as seen in the prereduction sagittal recon-
struction (Fig. 9-16C).
Proximal femur fractures. When the proximal femur is
fractured in high-impact trauma such as motor vehicle
collisions (MVC), it results in a more complex fracture of the
neck and intertrochanteric region than seen in the elderly. The
fracture in the femoral neck is often vertical, diagonal across
the femoral neck (Fig. 9-17B), or involves the basicervical
portion of the neck (Figs. 9-17C and 9-17D). The fracture
may involve both femoral neck and intertrochanteric region.
It may be comminuted. CT clarifies the nature of the fracture
(Fig. 9-17D).
3. Hip fractures rare in children
and adolescents
Pelvic fractures about hip common
Pubic rami
Iliac wing
Occasional
Femoral neck
Posterior dislocation
Proximal femoral epiphyseal separation rare
Slipped capital femoral epiphysis (SCFE)
Fortunately, fractures of the hip are uncommon in children
because, when they do occur, they often result in a bad outcome.
Fractures of the hip do not occur in children as a result of low-
impact trauma. The diagram (Fig. 9-18A) depicts the injuries sus-
tained in high-impact trauma: fractures of the femoral neck and
proximal femoral epiphyseal separations. These occur in either
motor vehicle accidents or falls from great height and are often
in association with fractures of the pelvis. Fractures of the pelvis
are usually obvious, but hip fractures and epiphyseal separations

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182      The Hip

A
B

C D E
FIGURE 9-18  The diagram (A) depicts the injuries sustained in high-impact trauma: fractures of the femoral neck and proximal
femoral epiphyseal separations. Fractures of the femoral neck, unlike those in adults, occur in the mid- or basicervical location (B, C) often in
association with pelvic fractures. Posterior dislocations of the hip are usually the result of trivial, low-impact trauma and similar in appearance to
those in adults (D). Frog-leg views of the hip are required either to disclose or to exclude epiphyseal separations of the hip with certainty (E).

may be subtle and easily overlooked. When a pelvic fracture is
identified in a child, examine the femoral neck and proximal
femoral physes and epiphyses closely for the signs of epiphyseal
separation: widening of the physis and offset of the epiphysis.
Fractures of the femoral neck, unlike those in adults, occur
in the mid- or basicervical location (Figs. 9-18B and 9-18C),
often in association with pelvic fractures.
On the other hand, posterior dislocations of the hip are usu-
ally the result of trivial, low-impact trauma and similar in appear-
ance to those in adults (Fig. 9-18D). Unlike adults, accompanying
fractures of the posterior rim of the acetabulum are uncommon.
Proximal femoral epiphyseal separations are rare. Epiphy-
seal separations may be minimally displaced and difficult to
identify on AP views. Frog-leg views of the hip are required
either to disclose or to exclude epiphyseal separations of the
hip with certainty (Fig. 9-18E).
4. Injuries likely to be missed
Low-impact trauma – elderly
Fine, subtle fractures
Femoral neck
Intertrochanteric
Impacted subcapital fractures distort the normal appear-
ance of the femoral head and neck profile. (Normal profile
shown in Fig. 9-19A.) The degree of impaction is variable.
When minimal, the radiographic findings may be difficult to
appreciate and easily overlooked. The impaction is usually due
to a valgus force, less commonly a varus force. With valgus
impaction the femoral head settles on the femoral neck later-
ally, eliminating the normal curvature at the junction of the
head and neck (Figs. 9-19B and 9-19C). The junction forms an
angular distortion with a broad linear band of sclerosis, denot-
ing impaction of bone, extending into the femoral neck. With
varus impaction the reverse occurs. The femoral head settles
on the femoral neck medially, forming an angular distortion
from which a band of sclerosis extends into the femoral neck
(see Fig. 9-7). Lesser degrees of fracture do not significantly
distort the head and neck junction. They are manifest by a
disruption of the cortical bone at the head and neck junction
(Figs. 9-19C and 9-19D). Minimal overriding of the fracture
fragments may be seen (Fig. 9-19D). Simple disruption of the
cortex without impaction or overriding (Fig. 9-19E) requires
close inspection to be confidently identified. CT can resolve
any questions regarding these findings and confirm the diag-
nosis with certainty.

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 The Hip     183

A B

C D E
FIGURE 9-19  Impacted subcapital fractures distort the normal appearance of the femoral head and neck profile. (Normal profile shown in A.)
With valgus impaction the femoral head settles on the femoral neck laterally, eliminating the normal curvature at the junction of the head and
neck (B, C). Lesser degrees of fracture do not significantly distort the head and neck junction. They are manifest by a disruption of the cortical
bone at the head and neck junction (C, D). Minimal overriding of the fracture fragments may be seen (D). Simple disruption of the cortex with-
out impaction or overriding (E) requires close inspection to be confidently identified.

Fractures of the greater trochanter have been shown

5. W
 here else to look when you see by MRI commonly to extend into the intertrochanteric
something obvious region of the femur, necessitating open fixation. There-
Obvious Look for
fore, once a fracture of the greater trochanter is identified
on radiographs (Figs. 9-21A and 9-21B), an MRI should
Fracture of femoral shaft Posterior dislocation of hip be performed to identify such extension (Fig. 9-21C, Cor
Fracture of acetabulum T1 MRI).
Fracture of femoral neck
Fracture of femur (condyles)
6. Where to look when you see nothing at all
Fracture of patella
Fracture of greater Intertrochanteric extension Search for alternative diagnoses, fractures of
trochanter (MRI) Iliac crest
Pubic rami
Fractures of the femoral shaft are frequently associated with Acetabulum
proximal injuries (Fig. 9-20A) about the hip (fractures of Greater trochanter of proximal femur
the femoral neck (Figs. 9-20B and 9-20C); posterior fracture Need to rule out obscure/not apparent femoral neck or
dislocations of the hip and acetabulum) and/or distal frac- intertrochanteric fracture
tures about the knee (metaphysis or condyles of the femur, If questionable radiographic findings noted – CT often
patella, and tibial plateaus or proximal metaphysis of the sufficient
tibia). After identifying a femoral shaft fracture, search for If x-rays negative – MRI required
these associated injuries. It is critical to ensure that femoral
shaft fractures are adequately imaged from the ipsilateral Alternative diagnoses. When the elderly fall, the clinical
pelvis to the entire knee to identify or exclude these inju- concern is almost always directed towards the possibility of
ries. Make certain the radiographs include the entire knee. hip fracture. Fractures of the pelvis may occur instead. Before
CT of the pelvis is obtained routinely in most high-impact you declare the examination of the hip negative, be certain
trauma and will demonstrate injuries in and about the hip to exclude the presence of alternative diagnoses (Fig. 9-22A),
and acetabulum. particularly fractures of the ipsilateral iliac crest (Figs. 9-22 B

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184      The Hip

Proximal

Midshift
fracture

Distal

B C
A
FIGURE 9-20  Fractures of the femoral shaft are frequently associated with proximal injuries (A) about the hip (fractures of the femoral neck
(B, C), posterior fracture dislocations of the hip and acetabulum, and/or distal fractures about the knee (metaphysis or condyles of the femur,
patella, and tibial plateaus or proximal metaphysis of the tibia).

A B C
FIGURE 9-21  Fractures of the greater trochanter have been shown by MRI commonly to extend into the intertrochanteric region of the femur,
necessitating open fixation. Therefore, once a fracture of the greater trochanter is identified on radiographs (A, B), an MRI should be performed
to identify such extension (C, Cor T1 MRI).

and 9-22C), superior and inferior pubic rami (Fig. 9-22D), as
well as taking a closer look at the acetabulum (Figs. 9-22E and
9-22F) and proximal tip of the greater trochanter for subtle
fractures (see Figs. 9-4 and 9-21).
If the radiographs are thought to be negative and there remains
a serious clinical concern of hip fracture, take another look at the
radiographs. Look closely at the femoral neck and intertrochan-
teric regions and greater trochanter on all views. Look again for
fractures of the acetabulum, body of the pubis and pubic rami,
and the iliac crest. If again negative (Fig. 9-23A), an MRI exami-
nation should be considered. If the patient is either unable to or
refuses to bear weight on the affected leg, this is a clear indication
for MRI (Fig. 9-23B, Cor Stir): note low signal subcapital fracture
of femoral neck with surrounding edema and hemorrhage.
Remember, you are presented with two tasks: first, you
must find an abnormality, if present, and second, you must
convince clinicians that an abnormality is present. If you see
a questionable abnormality on the radiographs, a CT exami-
nation of the hip will almost always confirm your diagnos-
tic suspicions and resolve any lingering questions about the
radiographic findings.
Similarly, should clinicians question your diagnosis, in this
case (Fig. 9-24A), a valgus-impacted subcapital fracture of
the left femoral neck, do not get into an argument about the
findings. Suggest a CT examination of the hip be obtained to
clarify the findings. The CT will likely lay to rest their concerns
by clearly depicting the abnormality you noted on the radio-
graphs (Figs. 9-24B, axial, and 9-24C, coronal reconstruction).

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 The Hip     185

A B C

D E F
FIGURE 9-22  Alternative diagnoses.  Before you declare the examination of the hip negative, be certain to exclude the presence of alterna-
tive diagnoses (A), particularly fractures of the ipsilateral iliac crest (B, C), superior and inferior pubic rami (D), as well as taking a closer look at the
acetabulum (E, F) and proximal tip of the greater trochanter for subtle fractures (see Figs. 9-4 and 9-21).

FIGURE 9-23  Negative radiograph for fractures of the

acetabulum, body of the pubis and pubic rami, and the iliac
crest (A). If the patient is either unable to or refuses to bear
weight on the affected leg, this is a clear indication for MRI (B,
A B Cor Stir): note low-signal subcapital fracture of femoral neck
with surrounding edema and hemorrhage.

FIGURE 9-24  A valgus-

impacted subcapital fracture
of the left femoral neck (A).
CT showing abnormality
A B C (B, axial, and C, coronal
reconstruction).

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