Check for hip dislocation and features of acetabular wall fracture.
Trace the femoral cortices and the proximal femoral trabeculae to evaluate for subtle fracture. Patterns of injury are best described first by location including the femoral head, subcapital femoral neck, femoral neck, basicervical neck, intertrochanteric femur, and subtrocahnteric femur.
In the osteopenic patient, MRI may be more sensitive in the detection of non-displaced fracture. At our institution, you can recommend a 4 minute “Rapid Pelvis” protocol for these circumstances.
Familiarize yourself with the common locations and radiographic appearances of hip fractures. Classification systems for each fracture location:
- Femoral head fracture dislocation- Pipkin classification
- Subcapital femoral neck fracture- Garden classification
- Intertrochanteric fracture- integrity of the posteromedial cortex.
Subcapital femoral neck are classified based on the degree of femoral head/neck separation as a contiguous unit. While CT is sometimes required to distinguish Garden I-II (stable) from Garden III-IV (unstable) fractures, the following fracture features should be described when definable on radiography:
- Valgus vs varus angulation
- Displaced vs non displaced
- Comminution
EXAMPLES:
Garden I- Incomplete subcapital femoral neck with slight valgus impaction.
Garden II- Nondisplaced fracture at the left subcapital femoral neck with probable extension of fracture plane to inferiormedial cortex.
Garden III- Mildly displaced, impacted fracture at the left subcapital femoral neck with varus alignment.
Garden IV- Completely displaced fracture of the left subcapital femoral neck.
Intertrochanteric fractures are generally classified based on the number of fracture fragments.
Intertrochanteric fracture with reverse obliquity describes a dominant, linear fracture plane which extends from the medial cortex superiorly to the lateral cortex inferiorly, usually with subtrochanteric extension.
Example report negative for traumatic injury.
FINDINGS:
- No acute fracture. Appropriate alignment of hip joint.
IMPRESSION:
- No acute fracture or dislocation.
- If there is clinical concern for occult hip fracture or the patient cannot bear weight, consider MRI for further assessment.