Fractures and D i s l o c a t i o n s of the Hip and Femur
By Martha A. Norris and Arthur A. De Smet
H E T O P I C O F trauma involving the hip
T and femur includes five main categories:
(1) dislocation of the hip; (2) fracture of the
femoral neck; (3) intertr0chanteric and subtro-
chanteric fractures; (4) fractures of the femoral
shaft; and (5) supracondylar fractures. In this
article, each of these topics will be discussed in
individual sections.
W h e n evaluating a patien t with trauma to the
hip and femur, the radiographic examination
should always include an anteroposterior (AP)
view of the pelvis, a cross-table lateral view of
the involved hip, and an AP and lateral view of
the femur, which includes the knee, If there is a
question of a minimally impacted but stable
subcapital fracture on the initial two films, a
frog,leg lateral view of the hip may be useful. To
image the entire femur, two films of each view
are frequently necessary. The femurs should be
slightly internally rotated on the AP pelvis film
in order to best demonstrate the femoral neck.
Without internal rotation, the neck will appear
foreshortened, and fractures are often obscured
(Figs 1A and 1B). 1
NORMAL ANATOMY OF THE HIP AND
PROXIMAL FEMUR
The femur is the longest bone in the body.
The articular surface of the femoral head is
smooth except for the medial depression formed
by the fovea capitis, the site of attachment of
the ligamentum teres. The femoral neck ex-
tends from the head to the trochanters and
forms a 115 ~ to 140~ angle with the femoral
shaft. The neck also angles anteriorly 125 ~ to
130 ~ so that the femoral head lies anterior to the
ABBREVIATIONS
AP, anteroposterior; CT, computed tomography
From the Department of Radiology, Universityof Wisconsin
Hospital and Clinics, Madiso~ WI.
Address reprint reqtceststo Martha A. Norris, MD, Depart-
ment of Radiology, University of Wisconsin Hospital and
Clinics, 600 Highland Ave, Madison, W153792.
Copyright 9 1994 by W.B. Saunders Company
003 7-198X/ 94/ 2902-000555~ O0/0
100
trochanters. The greater trochanter projects
superolaterally at the neck-shaft junction and
serves as the attachment of the gluteus muscles.
The lesser trochanter, inferior and medial to
the greater trochanter, is the insertion site for
the iliopsoas tendon. The trochanters are con-
nected posteriorly by the thick intertrochanteric
crest. The anteriorly located intertrochanteric
line is the site of attachment of the hip cap-
sule. a,2 An important structural component of
the femoral neck and intertrochanteric region is
the calcar femorale, an area of condensed
trabeculae that extends from the posterior as-
pect of the femoral neck, through the posterome-
dial intertrochanteric area, to the posterome-
dial cortex of the subtrochanteric region of the
femoral shaft. 3
HIP DISLOCATIONS
Dislocations of the hip are usually the result
of motor vehicle accidents or other severe
trauma. 1 The dislocation can occur in the poste-
rior, anterior, or central direction. Posterior hip
dislocations are the most common type, account-
ing for 85% to 90% of cases. The usual mecha-
nism of injury for posterior dislocations is the
flexed knee striking the dashboard during a
motor vehicle accident. 1,4,5Because of the sever-
ity of trauma associated with these dislocations
and the mechanism of injury, associated frac-
tures of the femoral shaft, tibia, patella, or
posterior lip of the acetabulum are common. L4.5
An AP view of the pelvis will readily show a
posterior dislocation with the femoral head
lying superior to and overlapping the acetabu-
lum. On physical examination, the leg is short-
ened. Radiographically, the femur is fixed in
internal rotation and adduction (Fig 2). 1,6 Typi-
cally, the lesser trochanter is not seen projecting
medially from the femur.
Femoral head fractures occur in up to 16% of
posterior hip dislocations. 7-9 These can be avul-
sion fractures at the attachment of the ligamen-
turn teres or impaction fractures from the femo-
ral head striking the acetabulum. Impaction
fractures are analogous to the Hill-Sachs frac-
ture of the humeral head resulting from an
anterior shoulder dislocation. 7,s,1~ The impac-
Seminars in Roentgenology, Vol XXIX, No 2 (April), 1994: pp 100-112