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
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.
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).
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.
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.
