Practice Essentials

Femoral neck fractures are serious injuries associated with a high mortality and significant
morbidity in the geriatric population. The incidence has increased since the 1960s and is
expected to continue to increase as life expectancies increase. [1, 2, 3] Despite advances in surgical
hardware and techniques, these injuries still pose a significant clinical challenge. The primary
complications arising from femoral neck fractures are nonunion and avascular necrosis (AVN).

Preferred examination

Radiography should always be the initial imaging modality. [4, 5] Then, depending on the clinical
concern, additional studies can be obtained. In the American College of Radiology (ACR)
Appropriateness Criteria, MRI is recommended if the presence of a fracture is equivocal on
radiographs. [5] Nuclear medicine scintigraphy may also be appropriate. [6, 5] CT scanning may be
useful if more osseous details (eg, degree of comminution and possible intra-articular bone
fragments) are required. [7, 8, 9, 10]

Ten percent of all hip fractures are occult on plain radiography, requiring further investigation to
ascertain the diagnosis. [11] Spiral fractures can be difficult to detect on a single view. Some
stress fractures may not be seen at all. In general, nondisplaced or minimally displaced fractures
are difficult to perceive on plain radiographs. Although MRI is considered the goal standard for
evaluation of suspected fractures in patients with a negative or equivocal radiograh, surgery
within 48 hours is associated with lower overall morbidity and mortality. Thus, if MRI is not
available within 24 hours or is contraindicated, CT should be performed. [11, 5]

Ultrasonography does not play a significant role in the routine evaluation of hip fractures.
However, this modality has been used in research to evaluate the degree of distention of the hip
joint capsule after fractures and in the study of elevated intracapsular pressures. Sonograms can
also depict the presence of an intracapsular hematoma, which is mildly echogenic, as
distinguished from synovial fluid, which is anechoic.

Classification of fractures

The Garden classification of subcapital femoral fractures is the most widely used today. This
system is used to describe fractures on the basis of the distortions of the principal (medial)
compressive trabeculae before reduction, as seen on anteroposterior (AP) radiographs. The
anatomic basis of the Garden classification system is depicted in the illustration below. [12]
Image depicting the trabecular system of the hip that is used in Garden staging.

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A stage I Garden fracture (seen in the images below) is an incomplete subcapital fracture. The
femoral shaft is twisted externally. The alignment of the trabeculations of the distal femoral neck
relative to the femoral head (which itself is adducted) causes the fracture to be in a valgus
configuration. In other words, the trabecular markings in the femoral neck are displaced away
from the midline relative to those in the femoral head. The altered angle of the trabeculations is
greater than 180º when viewed on the AP projection (normally 160º). Such fractures are
inherently stable.