Hip & proximal femur - Clinical Tree

Regularly overlooked injuries

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Femoral neck fracture—minimally displaced.
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Femoral neck fracture—inadequate assessment of the lateral radiograph.
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Pubic ramus fracture.
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Apophyseal injuries in the young.

The standard radiographs

AP of whole pelvis.

Lateral projection of the painful hip.

Abbreviations

AIIS, anterior inferior iliac spine;
ASIS, anterior superior iliac spine;
CT, computed tomography;
MRI, magnetic resonance imaging;
RTA, road traffic accident;
THR, total hip replacement.

Normal anatomy

AP view

Lateral view

AP and lateral views

The femoral neck should:

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Have a smooth and intact cortex—no buckle, no step, no ridge.
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Not show any transverse areas of sclerosis.

The intertrochanteric region should:

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Have an appearance identical to the same area on the opposite femur.
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Not show any black or lucent line crossing the intertrochanteric bone nor any interruption in the cortical margin of the greater trochanter.

Secondary centres (apophyses)

The femur and pelvis of an adolescent will show several small secondary centres (the apophyses).

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These should be radiographically identical on the two sides.
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An apophysis contributes to the eventual shape and contour of the bone but not to its overall length. Muscles originate from/insert into the apophyses.
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Each apophysis has a physis. The physis (ie the growth plate) is a particularly weak part of the developing skeleton.

Analysis: the checklists

Detailed inspection should focus on the specific clinical history. Thus…

An elderly patient has suffered a simple fall

Check for:

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A black line—a displaced fracture—across the femoral neck.
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A white line—impacted fracture—in the subcapital region.
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A fracture line through the subcapital region, through the trochanteric region, or through the subtrochanteric region.
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A fracture of a pubic ramus.

A few fractures are very difficult to detect. If the radiographs appear superficially normal it is important to check again and answer the following questions:

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Are the cortical margins of the femoral neck smooth and continuous, or is there a slight step?
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Have I checked the lateral radiograph carefully?

An adolescent patient has acute/chronic pain following athletic activity

Check that:

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The femoral apophyses are similar on the painful and unaffected sides.
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Check the iliac apophyses.

Patient of any age who has sustained high velocity trauma

Check all of the features described above and also check:

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The acetabulum: is it fractured?
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The femoral head: is it dislocated?
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For multiple fractures of the femur and/or the pelvis.

Hip pain in a young patient with no history of recent trauma

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Age 4–10 years: consider Perthe's disease of the femoral head.
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Around the age of puberty: consider slipped capital femoral epiphysis.
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Age 13–25 years: assess all of the femoral and iliac apophyses. Chronic repetitive stress can affect the tendinous or muscle attachment at an apophysis and produce soft tissue calcification or an apophyseal irregularity.

Normal AP view . Injured right hip. The radiographer centres the X-ray beam fairly low so that the proximal shaft of the femur is included. The injured and uninjured sides can be compared.

Normal lateral view. The same patient as above. The two sites that must be checked are the neck of the femur and the trochanteric region. This peculiar projection might seem anatomically counterintuitive—see explanation on p. 228 .

The common injuries

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