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.
Image depicting a Garden I hip fracture.

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Radiograph demonstrating a Garden I hip fracture.

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Magnetic resonance image of a Garden I hip fracture. Bone marrow edema is now present in the femoral
neck on this short-tau inversion recovery (STIR) image.

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A stage II Garden fracture (seen in the images below) is a complete, but nondisplaced, fracture.
The femoral head is abducted, but the femoral neck has moved in such a way as to maintain
normal alignment with the femoral head. These fractures are considered stable and have a
favorable prognosis.
Image depicting a Garden II hip fracture.

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Radiograph depicting a Garden II hip fracture.

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Sagittal T1-weighted magnetic resonance image of a Garden II hip fracture. This image demonstrates a
low-signal-intensity line that passes through the femoral neck.

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Coronal short-tau inversion recovery (STIR) magnetic resonance image of a Garden II hip fracture. This
image demonstrates bone marrow edema in the femoral neck, as well as edema in the adjacent muscles.
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A stage III Garden fracture (seen in the images below) is a complete, partially displaced
subcapital fracture. The femoral shaft is externally rotated. The femoral head is abducted and
axially rotated such that its superior surface resides more anteriorly. The alignment of the
femoral neck relative to the head is in varus deformity.

Image depicting a Garden III hip fracture.

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 Radiograph depicting a Garden III hip
fracture.

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A stage IV Garden fracture (seen in the images below) is a complete and fully displaced fracture.
The femur is externally rotated and superiorly displaced relative to the femoral head. The head,
now completely detached from the neck, remains in anatomic position relative to the acetabulum.
This fracture is considered unstable with a poor prognosis.
 Image depicting a Garden IV hip
fracture.

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Radiograph depicting a Garden IV hip

fracture.

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Avascular necrosis staging

The most widely used classification system for AVN of the femoral head is the one proposed by
Ficat and Arlet. [12, 13] This system is based on plain radiographic appearances, as follows:

 Stage 0 has no radiographic findings. This preclinical stage is diagnosed by MRI or bone scanning.
 Stage 1 manifests as slight osteoporosis on plain images. Clinical symptoms may be present, but
sclerosis is not.
 Stage 2 involves diffuse osteoporosis and sclerosis at the region of the infarction. The infarcted
area is well delineated due to a reactive shell of bone. The spherical shape of the femoral head is
maintained.
 Stage 3 results in the crescent sign, or a radiolucency under the subchondral bone, which
represents a fracture. The contour of the femoral head is abnormal. The joint space is preserved.
 Stage 4 is characterized by femoral head collapse, joint-space narrowing, and subchondral
sclerosis.

The Ficat-Arlet classification is especially pertinent in Garden III and IV fractures, in which
there is a significant incidence of AVN.

Radiography
Radiography remains the first-line modality for imaging and classifying femoral neck fractures.
Fractures can be broadly described according to their location along the femoral neck where the
fracture line is located. Therefore, descriptive terms, such as subcapital, midcervical, and
basicervical fractures of the neck are sometimes used. However, more specific descriptions are
necessary, especially in relation to orthopedic management. Radiographs of Garden hip fractures
I-IV are presented below. [9, 10]
 Radiograph demonstrating a Garden I
hip fracture.
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Radiograph depicting a Garden II hip

fracture.
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 Radiograph depicting a Garden III hip
fracture.
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Radiograph depicting a Garden IV hip

fracture.
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Degree of confidence

Radiography is the preferred initial imaging modality for evaluating femoral neck fractures
because of its near universal availability, its ease of acquisition, and its documented correlation
with surgical results over many years of use. However, radiography has some limitations (as
demonstrated in the image below). Spiral fractures are difficult to assess on a single view.
Comminution is also not as easily demonstrated as it is with CT scanning. Some stress fractures
are simply not visible on plain images.

Radiograph with a poor depiction of

an incomplete fracture of the left femoral neck.
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If the clinical suspicion for a femoral neck fracture is strong, even if it is not visible on
radiographs obtained during the initial evaluation, the patient can be further evaluated with MRI,
which shows bone marrow edema, or nuclear medicine bone scanning, which shows increased
tracer uptake.

Computed Tomography
CT scanning plays an increasingly important role in the evaluation of the hip after a fracture. CT
scanning is exquisitely useful for imaging abnormalities of the bone itself. Because of this
modality's superior resolution, cross-sectional capabilities, and amenability to image
reconstruction in the coronal and sagittal planes, CT scanning is useful for preoperatively
assessing fracture comminution and in postoperatively determining the extent of union (or lack
thereof). [8]

Magnetic Resonance Imaging

MRI is sensitive and specific in the detection of femoral neck fractures, because this modality
can show both actual fracture line and the resulting bone marrow edema (as demonstrated in the
images below). [14, 7]
 Magnetic resonance image of a
Garden I hip fracture. Bone marrow edema is now present in the femoral neck on this short-tau
inversion recovery (STIR) image.
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Sagittal T1-weighted magnetic resonance image of a

Garden II hip fracture. This image demonstrates a low-signal-intensity line that passes through
the femoral neck.
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 Coronal short-tau inversion recovery
(STIR) magnetic resonance image of a Garden II hip fracture. This image demonstrates bone
marrow edema in the femoral neck, as well as edema in the adjacent muscles.
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MRI is the premiere imaging modality, especially in the setting of stress fractures, which can
appear normal on initial plain images, because of the superior contrast of MRI when appropriate
pulse sequences are used, the modality's intrinsic spatial resolution, and MRI's ability to image in
multiple planes (coronal, axial, and, less commonly, sagittal).

Popular pulse sequences include coronal and axial T1-weighted and T2-weighted fat-suppressed
sequences, although several other bone marrow sequences can also be used. In practice, a large
field of view is generally used so that both hips and the bony pelvis can be imaged
simultaneously. Intravenous contrast enhancement is not routinely used in the assessment of
fractures. The fracture line can be visualized as linear low-signal-intensity areas surrounded by
bone marrow edema, which is hypointense relative to normal marrow on T1-weighted images or
hyperintense on T2-weighted images.

The drawbacks of MRI include its longer imaging time, its relative lack of widespread
availability, its higher costs, and the exclusion of patients with cardiac pacemakers and certain
metal hardware in their body. With continued technological advances, however, the imaging time
of MRI has decreased, as have the costs.

MRI is the most sensitive modality for detecting bone marrow changes that are related to AVN,
even when radiographic findings are normal; therefore, MRI is the imaging modality of choice in
this regard. When AVN is detected after surgical fixation for a femoral fracture, the patient can
become a candidate for placement of a prosthesis. More importantly, MRI can be used to detect
the early stages of ischemic necrosis in the femoral head, so that interventions can be initiated
before further damage occurs, such as femoral head collapse, secondary osteoarthritis, and
fragmentation.
Degree of confidence

MRI is currently the best imaging modality for detecting femoral neck fractures. Several facts
must be kept in mind, however. The normal bone marrow of the pelvis and hips can have an
appearance that is patchy and of intermediate signal intensity, corresponding to the persistence of
red marrow. Also, the subchondral area of the femoral head can sometimes have a thin rim of red
marrow. These normal variants should not be confused with fractures.

Fractures and contusions should not be confused with idiopathic transient osteoporosis of the hip.
Transient osteoporosis is an uncommon, self-limited disease that affects middle-aged men and
pregnant women. This condition appears as osteopenia on plain radiographs and as areas of
decreased T1 signal intensity and increased T2 signal intensity that generally extend from the
femoral head to the intertrochanteric line on MRI. Usually, only one hip is affected at a given
time. To complicate matters, transient osteoporosis can predispose patients to a fracture if proper
care (eg, protected weight bearing) is not implemented.

This potential risk is decreased with the use of images that are reconstructed in the orthogonal
planes and with newer multidetector CT (MDCT) scanners.

Nuclear Imaging
Approximately 80% of fractures can be visualized 24 hours after trauma, via diffusely increased
tracer uptake. [15] By 3 days after trauma, 95% of fractures are visualized, and maximal fracture
sensitivity is found at 7 days; this knowledge may be helpful in equivocal cases. Given the high
sensitivity of nuclear medicine studies, they can be used to diagnose suspected femoral neck
fractures that have not been confirmed by means of plain radiography.

(See the image below.)

Bone scan of the left hip. This image

shows increased uptake in the left femoral neck.
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Bryant et al concluded that single-photon emission computed tomography (SPECT) scanning
should be performed with planar bone scintigraphy for evaluation of suspected femoral neck
stress fractures. The investigators compared the accuracy of planar scintigraphy alone with that
of planar scintigraphy with SPECT for initial evaluation of femoral neck stress fractures in a
young military population. They retrospectively identified 38 patients who had undergone planar
scintigraphy and 33 patients who had undergone planar scintigraphy and SPECT before MRI of
the hips. In the patients who underwent planar scintigraphy alone, 12 fractures were identified; in
patients who underwent planar scintigraphy with SPECT, 13 fractures were identified. The
sensitivity of planar scintigraphy alone was 50%, and its accuracy for high-grade fractures was
12.5%. When planar scintigraphy was combined with SPECT, sensitivity was 92.3%, and
accuracy for high-grade fractures was 70%. [16]

When MRI is contraindicated, SPECT/CT can be used to assess blood supply within the femoral
head after femoral neck fracture to help predict the occurrence of AVN. [17] SPECT/CT has 92%
specificity and 77% sensitivity, which are comparable to that of MRI. [18]

Degree of confidence

Although sensitive, bone scintigraphy is not specific for fractures. Other processes, such as
infection, inflammation, and tumor formation, can also demonstrate increased radionuclide
uptake. However, in the right clinical setting (eg, known trauma), bone scintigraphy is highly
sensitive for the detection of fractures.