MSK X-Ray Series | Hip Fractures — What the Image Is Telling You

🦴 THE NATURE OF HIP FRACTURES 🦴

Hi Reader,

Welcome back to the MSK X-Ray Interpretation series. This week, we’re turning our attention to one of the most important fracture patterns you’ll encounter in clinical practice — the hip fracture.

If you're finding these emails useful, but are still struggling to plan your rehab programmes for patient’s or clients drop me an email for my availability where we’ll discuss the problems together to develop your skill set and clinical expertise.

Now let's get into this weeks edition.

Whether you’re working in an acute orthopaedic ward, a rehabilitation setting, or MSK outpatients, understanding what you’re looking at on the image will sharpen your clinical reasoning and help you ask better questions of the wider MDT.

Hip fractures represent a significant proportion of fragility fractures, predominantly affecting older adults with osteoporosis, though they can occur across all age groups following high or low-energy trauma. They carry substantial morbidity and mortality risk - making early, accurate identification and timely rehabilitation critical to the patient , and your career, if we're being completely honest.

On imaging, your primary reference points are the femoral neck, the trochanters, and the proximal femoral shaft, remind yourself of these points on the image above before continuing. As the location of the fracture line determines the classification, this will directly inform surgical management and therefore your rehabilitation approach.

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📍 THE THREE COMMON TYPES

1. Intracapsular (Femoral Neck) Fractures

These occur within the hip joint capsule, between the femoral head and the base of the femoral neck. Because the blood supply to the femoral head runs along the femoral neck, these fractures carry a high risk of avascular necrosis. Surgical management is typically hemiarthroplasty or total hip replacement, depending on the patient’s pre-morbid function and fracture displacement.

On X-ray: Look for disruption of Shenton’s line (see below)

2. Extra capsular Fractures

This will occur between the greater and lesser trochanters, these type of fractures have a more reliable blood supply with lower risk of avascular necrosis (AVN). They are typically managed with dynamic hip screw (DHS) fixation or intramedullary nailing.

On X-ray: The fracture line runs obliquely between the two trochanters (see the above image).

3. Subtrochanteric Fractures

These occur below the lesser trochanter, within the proximal femoral shaft, these are less common but could become complex, especially if multi fragmented. The region experiences high compressive and tensile forces, making fixation challenging and rehabilitation more prolonged. Patients on long-term bisphosphonate therapy can be a high risk of this fracture pattern, which can make rehab challenging and complex. Surgical management usually consists of an open reduction internal fixation (ORIF) or intramedullary nail.

On X-ray: The fracture line sits distal to the lesser trochanter (see the above image).

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As always, X-ray interpretation is a skill that develops through consistency, with your deliberate practice. I’d encourage you to review images that illustrate each fracture type and repeatedly review X-Ray’s in your clinical practice to improve your expertise.

Until next week,
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Warren Caffrey | WLC Physio

@WLCPhysio on all social media platforms.