Applied Anatomy of Hip Fractures using Computed Tomography

Applied Anatomy of Hip Fractures using Computed Tomography

Interactive Learning Tool

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Learning Objectives

• Describe the skeletal anatomy of the hip
• Identify predisposing factors for hip fractures
• Explain the mechanisms of hip fractures
• Explain hip fracture classification systems
• Evaluate the role of CT in hip fractures compared with plain radiography
• Outline the management of different hip fracture types
• Identify complications associated with hip fractures

Prevelance of Hip Fractures

• Second most common fracture location after distal radius (wrist).
• Most common fracture in the elderly population.
• ~95% occur in individuals over 65 years of age.
• Approximately 1.6 million hip fractures occur annually.
• ~70% occur in women.

Right Hip Anterior view

Anatomy of the Hip Joint

• Ball-and-socket joint: formed by the femoral head and acetabulum.
• Acetabulum: formed by the ilium, ischium and pubis.

• Articular cartilage covers joint surfaces to reduce friction and distribute load.
• Acetabular labrum deepens the socket and enhances joint stability.
• Fibrous joint capsule encloses the joint, providing stability while allowing movement.
• Strong ligaments reinforce the joint and limit excessive motion.

Hover over the markers to explore key anatomical structures.

Anatomy of the Pelvis and Acetabulum

Superior

Superior

Right Pelvis Lateral view

The acetabulum can be conceptually divided into anterior and posterior columns and walls (Judet–Letournel classification), which form its structural framework.

• Anterior column = yellow
• Anterior wall = green
• Posterior column = blue
• Posterior wall = red

Anterior

Anterior

Posterior

Posterior

Inferior

Inferior

Colours indicate approximate anatomical regions.

Blood Supply of the Hip

Femoral artery

• Gives rise to the medial and lateral ciurcumflex arteries.
• Medial circumflex artery: main supply to femoral head.
• Ascending branches of the circumflex arteries anastomose to form the extracapsular arterial ring.
• Extracapsular ring gives intracaspsular retinacular branches.
• Retinacular arteries: supply femoral neck and head.
• Extracapsular network: main supply to intertrochanteric region.
• Perforating branches of the femoral artery: supply subtrochanteric region.

Foveal artery

• Branch of the obturator artery (via the acetabular branch).
• Passes through the acetabular notch to the fovea of the femoral head.
• Provides a minor contribution to femoral head blood supply.
• More significant in children.

Right Hip Anterior view

Mechanical Influences on Hip Fracture Risk

Coxa Vara

Normal Hip

Coxa Vara

• Reduced femoral neck–shaft angle (<120°) alters load distribution across the hip.

• Increased shear and bending stresses accross the femoral neck predispose to stress fractures.

Repetitive Loading

• Repetitive loading (e.g. in athletes) increases cumulative mechanical stress across the femoral neck potentially leading to stress fractures.

Biological Influences on Hip Fracture Risk

Ageing and osteoporosis reduce bone mineral density (BMD), weakening bone structure.Structural changes

• Loss of trabecular bone mass and connectivity.
• Increased porosity of cortical bone.
• Thinning of trabeculae reduces structural strength.

Cellular mechanisms

• Reduced osteoblast activity and increased osteoclast activity lead to net bone loss.
• Postmenopausal oestrogen decline accelerates bone resorption.

Clinical relevance

• Increases fracture risk, particularly in the proximal femur.
• Predisposes to fragility fractures following low-energy trauma.

Healthy bone

Weak bone

Additional Risk Factors for Hip Fractures

Hip fracture risk is multifactorial, influenced by mechanical, biological, and lifestyle factors.

Mini Quiz

Anatomy recap

Start

Identify the Hip Joint Structures

Drag and drop the labels onto the red dots to identify each structure.

Lesser trochanter

Acetabulum

Femoral head

Greater trochanter

Pubis

Ischium

Ilium

Femoral neck

Femoral shaft

Multiple Choice

Identify the Acetabular Columns and Walls

Drag and drop the labels onto the dots to identifty the coloured regions.

Posterior column

Posterior wall

Anterior column

Anterior wall

True or False

Computed Tomography (CT)

• Cross-sectional imaging technique producing detailed 3D visualisation.
• Superior to radiography for assessment of complex fractures.
• Allows 3D reconstruction for improved understanding of fracture geometry.
• Enables evaluation of fracture alignment, comminution, and joint involvement.
• Commonly performed following radiographs when occult fracture or complexity is suspected.
• Essential for assessing fracture stability, displacement, and surgical planning.

CT in Hip Fratures

Femoral head

Femoral neck

Axial CT of the right acetabulum showing anterior wall (AW), posterior wall (PW), anterior column (AC), posterior column (PC), and the femoral head and neck.

3D CT reconstruction of the pelvis illustrating acetabular morphology and fracture location (arrows).

Source

Source

Types of Hip Fractures

• Hip fractures are classified based on anatomical location.

Main fracture types include:

• Femoral neck
• Femoral head
• Acetabular
• Intertrochanteric
• Subtrochanteric

• Further classification depends on fracture pattern, displacement, and comminution.

Hip Fracture Causes

Hip fractures result from direct or indirect forces applied to the proiximal femur.

Direct Impact

Indirect Mechanisms

High-energy trauma

Dashboard injury

Low-energy trauma

Axial-loading

Intracapsular Fractures: Femoral Neck

• One of the most common hip fractures in elderly populations.
• Typically caused by low-energy falls from standing height onto the lateral hip.
• Commonly classified using the Garden and Pauwels systems.

Femoral Neck Fractures: Garden Classification

• The Garden classification describes the degree of displacement of a femoral neck fracture.
• It was established in 1961 by British orthopaedic surgeon Robert Symon Garden.

Type II

Type IV

Type III

Type I

Complete fracturePartially displaced

Complete fractureFully displaced

Complete fractureNon-displaced

Incomplete fracture

Femoral Neck Fractures: Pauwels classification

• The Pauwels classification is based on the angle of the fracture line relative to the horizontal on anteroposterior radiographs following reduction.
• The Pauwels angle may also be assessed using CT.
• Lower angles indicate greater stability and a more favourable prognosis.

Type II

Type III

Type I

<30°

30-50°

>50°

True or False

CT for Femoral Neck Fractures

• Detects occult fractures not visible on plain X-ray.
• Assesses fracture displacement, orientation and stability.
• Enables accurate measurement of fracture angle.

Distal fragment displacement

Occult Stress Fractures

Pauwels classification

Complete the sentence

Femoral Neck Fracture Management

Non-operative

• Rare.
• Used in high-risk or non-ambulatory patients.

Operative Young patients

• Typically require urgent open reduction and internal fixation

• Non-displaced fractures: often treated with cannulated screws.
• Displaced fractures: typically treated with a dynamic hip screw (DHS).

Elderly patients

• Typically require a hip replacement.
• Less active patients: hemiarthroplasty.
• More active patients: total hip arthroplasty.

(ORIF).

Femoral Neck Fracture Risks

Avascular necrosis (AVN)

• Bone death by lack of blood supply.

• A major risk of femoral neck fractures.

• Damaged arteries distrupts blood flow to the femoral neck and head region.

Nonunion

• Healing of the fracture in an incorrect position.
• May result in altered hip biomechanics and limb shortening.
• Can lead to pain, reduced function, and early osteoarthritis.

Healthy Bone

AVN

+ info

True or False

Intracapsular Fractures: Femoral Head

• Rarest proximal femur fracture.
• ~⅔ occur in younger patients.
• Commonly associated with hip dislocation.
• Often associated with acetabular fractures.
• Mechanisms include dashboard injury or axial loading from a fall onto the feet.
• Classified using the Pipkin and Brumback systems.

Femoral Head Fractures: Pipkin Classification

• The Pipkin classification was established in 1957 by Garett Pipkin.
• More widely used than the Brumback classification.
• The types typically occur with hip dislocations, most commonly posterior hip dislocations (PHDs).

Type III

Type II

Type I

Type IV

Fracture superior to the fovea capitis

Fracture inferior to the fovea capitis

Type I or II with associated femoral neck fracture

Type I or II with associated acetabular rim fracture

Femoral Head Fractures: Brumback Classification

• The Brumback classification was established in 1987 by Robert Brumback and colleagues.

• Provides a more detailed classification than Pipkin, incorporating dislocation type.
• Less widely used due to increased complexity and limited impact on clinical decision-making.
• All types involve a femoral head fracture with the exception of type IIIa.

Type V

Type IV (A&B)

Type III (A&B)

Type II (A&B)

Type I (A&B)

Posterior dislocation

Posterior dislocation

Unspecified dislocation

Anterior dislocation

Central dislocation

IA

IIIA

IIA

IVA

Femoral neck fracture

Inferomedial femoral head fracture

Superomedial femoral head fracture

Femoral head fracture

Femoral head fracture

True or False

CT for Femoral Head Fractures

• Detects intra-articular fragments.
• Assesses joint congruity.
• Identifies associated acetabular fractures.

Intra-articular Fragment

Associated Acetabular Fracture

Multiple Choice

Femoral Head Fracture Management

Non-operativePipkin type I and II

• Conservative management if displacement < 1mm following reduction.
• Partial weight-bearing 4-6 weeks following fracture is recommended.
• Adduction and internal rotation should be avoided during early rehabilitation.

Operative

• Headless compression srews often used in ORIF.

Pipkin type I and II

• ORIF if fracture displacement >1mm.

Pipkin type III and IV

• Younger patients: often ORIF.
• Older patients: ORIF or arthroplasty depending on fracture

complexity and bone quality.

Femoral Head Fracture Risks

Heterotopic ossification (HO)

• Abnormal bone formation in peri-articular soft tissues.
• Most common compliaction.
• Occurs following trauma or surgical fixation.

Post-traumatic osteoarthritis

• Due to cartilage damage and joint incongruity.

Avascular necrosis (AVN)

• Due to disruption of femoral head blood supply.
• Increased risk in Pipkin type III (associated neck fracture).

Sciatic nerve damage

• Associated with posterior dislocations.
• May cause motor and sensory deficits.

Complete the sentence

Acetabular Fractures

• More common than femoral head fractures.
• Typically result from high-energy trauma (e.g. road traffic collisions, falls from height).
• Mechanisms include dashboard injury or axial loading from a fall onto the feet.
• Classified using the Judet–Letournel system.

Acetabular fractures: Judet-Letournel Classification

• The Judet-Letournel Classification was established in 1964 by Robert Judet, Jean Judet, and Emile Letournel and is widely used.

Elementary Fractures: Simple fracture involving a single wall or column

IIIa

Transverse

Anterior column

Anterior wall

Posterior wall

Posterior column

Associated Fractures: Involve two or more elementary fracture patterns

Anterior column + posterior hemitransverse

Transverse + posterior wall

Posterior column + posterior wall

Both columns

T-shaped

True or False

CT for Acetabular Fractures

• Detects comminution.
• Identifies intra-articular fragments and joint involvement.
• Supports surgical planning by determining surgical approach (anterior vs posterior).

Fracture Comminution

3D CT Reconstruction

Complex Fracture Patterns

Multiple Choice

Acetabular Fracture Management

Non-operative

• Stable, concentrically reduced fractures without superior dome involvement.
• Fractures maintaining joint congruency and stability.
• Roof arc angle >45° on standard radiographic views.
• Selected low-pattern fractures (anterior column, transverse, T-shaped).
• Both-column fractures with secondary congruency.

Operative

• Most displaced acetabular fractures require ORIF.
• Indicated when joint congruency is disrupted or displacement >2 mm.
• Fixation uses pre-contoured buttress plates and screws or a percutaneous screw fixation to restore the articular surface.
• Surgical approach depends on fracture pattern (anterior vs posterior).
• Accurate anatomical reduction is essential to prevent post-traumatic osteoarthritis.
• Total hip arthroplasty may be considered in elderly patients with severe comminution or poor bone quality.

Acetabular Fracture Risks

Heterotopic Ossification (HO)

• Abnormal bone formation in peri-articular soft tissues.
• Most common complication.

Post-traumatic arthritis

• Due to cartilage damage and joint incongruity.
• Associated with displacement (>2 mm) and comminution.

Sciatic nerve damage

• Associated with posterior dislocation or posterior wall fractures.
• May result in motor and sensory deficits.

Avascular necrosis

• Due to disruption of femoral head blood supply.
• Most commonly associated with hip dislocation.
• Can occur even without direct femoral head fracture.

Sciatic nerve (posterior acetabulum)

Complete the sentence

Extracapsular Fractures: Intertrochanteric

• Common, especially in elderly patients with osteoporosis.
• Typically results from lateral hip impact (greater trochanter).

• Female predominance.
• Classified using AO/OTA and Evans–Jensen systems.

Intertrochanteric Fractures: AO/OTA Classification

• OA/OTA established in 1987 by the AO Foundation and the Orthopaedic Trauma Association.
• Most recently revised in 2018.

• 31A: "Femur, proximal end segment, trochanteric region fracture".
• Pertrochanteric: "through both trochanters".
• Intertrochanteric: "between trochanters".

31A3

31A2

31A1

Stable

Unstable

Unstable

A1.2

A2.2

A3.2

Multifragmentary pertrochanteric, lateral wall incompetent (< 20.5 mm) fracture

Simple pertrochanteric fracture

Intertrochanteric (reverse obliquity) fracture

Intertrochanteric Fractures: Evans-Jensen Classification

• The Evans-Jensen classification was adadpted from the Evans classification in 1975 by Jensen and Michaelsen which became more widely used.
• Less commonly used than the AO/OTA classification system.

Type III

Type IV

Type V

Type II

Type I

stable

stable

unstable

unstable

unstable

Three-part fracture with greater trochanter fragment

Three-part fracture with lesser trochanter fragment

Two-part fracture displaced

Two-part fracture non-displaced

Four-part fracture

Multiple Choice

CT for Intertrochanteric Fractures

• Detects occult fractures.
• Identifies comminution patterns for classification.
• Assesses posteromedial cortex integrity.

Occult Intertrochanteric Fractures

Communition Patterns and Classification

Multiple Choice

Intertrochanteric Fracture Management

Non-operative

• Rare
• Used for high-risk / non-ambulatory patients

Operative

• Stable (A1) fractures: dynamic hip screw.
• Unstable (A2 & A3) fractures: cephalomedullary nails.
• Arthroplasty is rare and reserved for severe fractures involving

multiple fragments, poor bone quality or implant failure.

Intertrochanteric Fracture Risks

• High mortality (~20–30% at 1 year).
• Significant blood loss due to extracapsular fracture (lack of tamponade effect), potentially leading to anemia.

Comorbidites

• Many patients who obtain an intertrochanteric fracture have multiple comorbidites, delaying surgery and increasing risk of complications.
• Circulatory, respiratory and nervous system contraindications must be exluded prior to surgery.

Non-operative Risks

• Thromboembolism including deep vein thrombosis (DVT).

• Cardiopulmonary and sepsis complications.

Operative Risks

• DVT risk increases further following surgery.
• Lag screw cut-out implant failure whereby fixation screw migrates superiorly and breaks through the femoral head into the joint cavity.
• Reverse oblique and transverse fractures (31-A3) have a relatively higher risk of implant failure.

Complete the sentence

Subtrochanteric Fractures

• Subtrochanteric region is defined at within 5cm inferior to the lesser trochanter.
• Less common than femoral neck and intertrochanteric fractures.
• Younger patients typically high-energy trauma e.g. motorbike accidents or contact sports.
• Older patients typically low energy trauma e.g. fall.
• Often associated with intertrochanteric fractures

Subtrochanteric Fractures: Seinsheimer Classification

• The Seinheimer classification was established in 1978 by Frank Seinsheimer.
• Most commonly used system for subtrochantreic fractures.

Type I

Type V

Type IV

Type III (A&B)

Type II (A,B&C)

IIA

IIIA

Subtrochanteric fracture with extended fracture through greater trochanter

Non-displaced fracture fragments

Two-part fracture

Three-part fracture

Four-part fracture

True or False

CT for Subtrochanteric Fractures

• Less commonly required for detection, as fractures are usually visible on radiographs.
• Subtrochanteric fractures are often displaced due to strong deforming muscle forces.
• CT (including 3D reconstruction) enhances visualisation of fracture displacement.
• Supports surgical planning by defining fragment configuration.

Displaced Subtrochanteric Fractures

3D CT Reconstruction

Complete the sentence

Subtrochanteric Fracture Management

Open-fractures

• Require immediate antibiotic treatments

Non-operative

• Very rare
• Used for high risk/ non-ambulatory patients

Operative

• Almost always treated operatively due to mechanical instability, causing pain and deformity
• End-of-bed skeletal traction whereby a weight is used via a tibial pin to counteract deforming muscle forces may be used.
• ORIF is typically required often using cephalomedullary nailing.
• Over-valgus correction with dynamic screws may be used.

Subtrochanteric Fracture Risks

• High mortality (~25% at 1 year).
• Significant blood loss due to disruption of perforating vessels and extracapsular fracture location (lack of tamponade effect), potentially leading to anaemia.

Mechanical factors

• Strong muscle forces contribute to fracture deformity.

• High mechanical stress contributes to instability.

Operative and healing complications

• Malunion: fracture heals in an abnormal position

(e.g. varus deformity), particularly if a DHS is used.

• Nonunion of proximal and distal segments.

• Implant failure may include screw cut-out or screw breakage.

Multiple Choice

Post-operative Recovery and Long-term Outcomes

Rehabilitation

Functional Impact

Final Quiz!

Start

Complete the sentence

Multiple Choice

Match Hip Fracture Types to Their Key CT Imaging Features

Drag each black circle to the corresponding red circle.

Complex fracture patterns

Femoral head

Femoral neck

Intra-articular fracture fragments

Fracture displacement

Acetabular

Fracture orientation and rotation

Interochanteric

Identify the Orthopaedic Implants

Drag and drop the labels onto the red dots to identify each implant.

Cephalomedullary nail

Headless compression screws

Hemiarthroplasty

Total hip arthroplasty

Percutaneous screws

Buttress plates

Dynamic hip screw

Multiple Choice

Identify the Type of Fracture

Drag and drop the labels onto the red dots to identify each frature.

Intertrochanteric

Acetabular

Femoral head

Femoral neck

Match Hip Fracture Types to Their Most Characteristic Complications

Drag each black circle to the corresponding red circle.

Malunion

Femoral neck

Sciatic nerve injury

Femoral head

AVN

Intertrochanteric

Screw cut-out failure

Subtrochanteric

Multiple Choice

Identify the Acetabular Fracture Types

Drag and drop the labels onto the red dots to identify each fracture.

Anterior column

Posterior wall

Transverse

Posterior column

Anterior wall

Transverse + posterior wall

Order by Prevalence

Summary of Key Points

• Hip fractures vary by anatomical location and mechanism.
• Classification systems guide diagnosis and management.
• CT provides additional detail in complex fracture patterns.
• Management depends on fracture type and patient factors.
• Complications vary depending on fracture type and patient factors.

Well Done!

You have now completed the learning resource.

References

• Akbarian, E., Mohammadi, M., Tiala, E., Ljungberg, O., Sharif Razavian, A., Magnéli, M. and Gordon, M. (2024) ‘Development and validation of an artificial intelligence model for the classification of hip fractures using the AO-OTA framework’, Acta Orthopaedica, 95, pp. 340–347. Available at: https://doi.org/10.2340/17453674.2024.40949 • Alfahad, A., Thet, E.M., Radwan, F., Sudhakar, J., Nini, K. and Tachtatzis, P. (2012) ‘Spontaneous incomplete transverse subtrochanteric femoral fracture with cortical thickening possibly secondary to risedronate use: A case report’, Journal of Medical Case Reports, 6, Article 272. Available at: https://doi.org/10.1186/1752-1947-6-272 • Aneskey (2017) Fractures and dislocations of the femur. Available at: https://aneskey.com/fractures-and-dislocations-of-the-femur/ (Accessed: 12 March 2026). • AO Foundation (n.d.) AO/OTA Fracture and Dislocation Classification Compendium—2018. Available at: https://www.aofoundation.org/trauma/clinical-library-and-tools/journals-and-publications/classification (Accessed: 17 March 2026). • AO Foundation (n.d.) Basic principles of intramedullary nailing. AO Surgery Reference. Available at: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/basic-technique/basic-principles-of-im-nailing (Accessed: 20 March 2026). • Apivatthakakul, T. and Oh, J.-K. (n.d.) ORIF – mini-fragment or headless screws for femoral head split fracture. In: AO Surgery Reference. Available at: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/proximal-femur/femoral-head-fracture-split/orif-mini-fragment-or-headless-screws (Accessed: 23 March 2026). • Ashraf, J., Kumar, A., Khan, R. and Mittal, S. (2020) ‘Management of subtrochanteric fractures of femur: a narrative review’, Journal of Musculoskeletal Surgery and Research, 4(2), pp. 72–81. Available at: https://doi.org/10.4103/jmsr.jmsr_6_20 • Atlas of Radiological Images (n.d.) Subtrochanteric fracture of femur, pathologic fracture, bone metastasis. Available at: https://atlas.mudr.org/Case-images-Subtrochanteric-fracture-of-femur-pathologic-fracture-bone-metastasis-896 (Accessed: 28 March 2026). • Attum, B. and Pilson, H. (2023) Intertrochanteric femur fracture. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK493161/ (Accessed: 21 March 2026). • Axenhus, M., Chammout, G., Kelly-Pettersson, P., Mukka, S., Magnéli, M. and Sköldenberg, O. (2025) ‘Long-term outcomes of cemented compared to uncemented femoral stems in total hip arthroplasty for displaced femoral neck fractures in elderly patients’, European Journal of Trauma and Emergency Surgery, 51, Article 73. Available at: https://doi.org/10.1007/s00068-024-02735-0

References

•• Bodanapally, U.K. and Dattwyler, M.P. (2019) ‘Acetabular fractures: A stepwise approach to identification and classification on 2D computed tomography’, Applied Radiology, (4), pp. 17-23. Available at: https://www.appliedradiology.com/Articles/acetabular-fractures-a-stepwise-approach-to-identification-and-classification-on-2d-computed-tomography (Accessed: 20 March 2026). • Bone School (n.d.) Femoral head fractures. Available at: https://www.boneschool.com/lower-limb/hip/femoral-head-fractures (Accessed: 15 March 2026). • Butler, M., Forte, M.L., Kane, R.L., Joglekar, S.B. and Swiontkowski, M.F. (2009) ‘Treatment of common hip fractures’, Evidence Report/Technology Assessment, 184, pp. 1–85. Available at: https://www.researchgate.net/profile/Mary-Butler-16/publication/46094260_Treatment_of_common_hip_fractures/links/0deec537cdea7905d6000000/Treatment-of-common-hip-fractures.pdf (Accessed: 17 March 2026) • Campos, A. (2025) Dynamic hip screw. Radiopaedia.org. Available at: https://radiopaedia.org/articles/dynamic-hip-screw (Accessed: 20 March 2026). • Carpintero, P., Caeiro, J.R., Carpintero, R., Morales, A., Silva, S. and Mesa, M. (2014) ‘Complications of hip fractures: a review’, World Journal of Orthopedics, 5(4), pp. 402–411. Available at: https://doi.org/10.5312/wjo.v5.i4.402 • Carpintero, P., Leon, F., Zafra, M., Serrano-Trenas, J.A. and Román, M. (2003) ‘Stress fractures of the femoral neck and coxa vara’, Archives of Orthopaedic and Trauma Surgery, 123, pp. 273–277. Available at: https://link.springer.com/article/10.1007/s00402-003-0514-z • Carter, S., Fahrenhorst-Jones, T. and Bickle, I. (2021) Cannulated screws. Reference article, Radiopaedia.org. Available at: https://doi.org/10.53347/rID-88038 • Chan, D.B. (2022) Femoral head fracture (Pipkin II) treated with surgical dislocation / trochanteric osteotomy. Orthopaedic Research and Innovation Foundation. Available at: https://www.osteosynthesis.org/42327651-femoral-head-fracture-pipkin-ii-treated-with-surgical-dislocation-trochanteric-osteotomy (Accessed: 15 March 2026). • Chan, S.S., Rosenberg, Z.S., Chan, K. and Capeci, C. (2012) ‘Subtrochanteric femoral fractures in patients receiving long-term alendronate therapy: imaging features’, American Journal of Roentgenology, 194(6), pp. 1581–1586. Available at: https://doi.org/10.2214/AJR.09.3588 • Chandra, A. and Rajawat, J. (2021) ‘Skeletal aging and osteoporosis: mechanisms and therapeutics’, International Journal of Molecular Sciences, 22(7), Article 3553. Available at: https://doi.org/10.3390/ijms22073553 • Cone, N. and Lee, J.E. (2023) ‘Older adult communication types and emotional well-being outcomes during COVID-19 pandemic’, BMC Geriatrics, 23(1), Article 178. Available at: https://doi.org/10.1186/s12877-023-03856-8

References

•Cong, Y., Wang, B., Fei, C., Zhang, H., Li, Z., Zhu, Y., Zhuang, Y., Wang, P. and Zhang, K. (2024) ‘Dynamic observation and risk factors analysis of deep vein thrombosis after hip fracture’, PLOS ONE, 19(6), Article e0304629. Available at: https://doi.org/10.1371/journal.pone.0304629 • De Biase, P., Biancalani, E., Martinelli, D., Cambiganu, A., Bianco, S. and Buzzi, R. (2018) ‘Subtrochanteric fractures: two case reports of non-union treatment’, Injury, 49(Suppl. 4), pp. S9–S15. Available at: https://doi.org/10.1016/j.injury.2018.11.038 • de Joode, S.G.C.J., Kalmet, P.H.S., Fiddelers, A.A.A., Poeze, M. and Blokhuis, T.J. (2019) ‘Long-term functional outcome after a low-energy hip fracture in elderly patients’, Journal of Orthopaedics and Traumatology, 20, Article 20. Available at: https://doi.org/10.1186/s10195-019-0529-z • Deleanu, B., Prejbeanu, R., Crisan, D., Vermesan, D., Predescu, V., Iacob, M. and Dema, A. (2015) ‘Subtrochanteric fracture as first sign of metastatic breast cancer: case presentation’, Journal of Medical Cases, 6(8), pp. 367–372. Available at: https://doi.org/10.14740/jmc2216w • Delgado-Martínez, A.D., Cañada-Oya, H. and Zarzuela-Jiménez, C. (2025) ‘Dynamic, over-valgus correction without osteotomy for nonunion of subtrochanteric hip fractures using a dynamic hip screw’, Applied Sciences, 15(3), Article 1236. Available at: https://doi.org/10.3390/app15031236 • Desauge, P.L., Aubert, T., Marteau, V., Upex, P., Jouffroy, P. and Riouallon, G. (2022) ‘Identification and treatment of atypical acetabular fractures having an independent acetabular roof fragment: Three-column fractures’, Orthopaedics & Traumatology: Surgery & Research, 108(2), Article 103209. Available at: https://doi.org/10.1016/j.otsr.2022.103209 • Dunseath, O.A., Al-Obaidi, I., Ignatius, L., Rudran, B. and Jordan, C. (2026) ‘Femoral head fractures: anatomy, diagnosis and management’, EFORT Open Reviews, 11(3), pp. 175–182. Available at: https://doi.org/10.1530/EOR-2025-0026 • El-ashhab, G.M., El Karamany, M.M., Halawa, M.A. and Elsaka, S.H. (2019) ‘Percutaneous screw fixation of acetabular fractures’, Benha Medical Journal, 36(2), pp. 1–16. Available at: https://doi.org/10.21608/bmfj.2019.14308.1001 • Ferguson, T. and Forward, D. (n.d.) Decision making: Nonoperative vs surgical treatment. AO Surgery Reference. Available at: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/acetabulum/further-reading/decision-making-nonoperative-vs-surgical-treatment (Accessed: 21 March 2026). • Gadi, D., Singh, R., Anand, V. and Pathak, S. (2015) ‘Unique simultaneous dual mechanism based bilateral femoral head fracture secondary to posterior dislocation of hip: A rare case report’, International Journal of Medicine, 3(2), pp. 112–114. Available at: https://doi.org/10.14419/ijm.v3i2.5183

References

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References

• Slattery, D. (n.d.) Hip arthritis. Available at: https://davidslattery.com/hip-conditions/arthritis/description/ (Accessed: 23 March 2026). • Sulaiman, S.R.K., Alturk, Y.M., Alarabi, R.M., Alsisi, E.M., Rajeh, A.A. and Sulaimani, A.B. (2022) ‘Uncommon presentation of bilateral subtrochanteric insufficiency fractures in young male associated with hypogonadism: A case report’, Journal of Musculoskeletal Surgery and Research, 6(2), pp. 184–188. Available at: https://doi.org/10.25259/JMSR_1_2022 • Sun, M., Liang, H., Bai, T., Zhang, T., Xu, R., Duan, S. and Cai, Z. (2024) ‘A comparative study of X-ray and 3D CT in the evaluation of Pauwels classification for femoral neck fractures’, Research Square [Preprint]. Available at: https://doi.org/10.21203/rs.3.rs-5339390/v1 • Swayambunathan, J., Dasgupta, A. and Bhattacharyya, T. (2021) ‘The pronounced impact of hip fractures on psychosocial wellbeing’, Journal of the American Academy of Orthopaedic Surgeons, 29(1), pp. e22–e30. Available at: https://doi.org/10.5435/JAAOS-D-19-00530 • Taosuwan, S. and Yuenyongviwat, V. (2024) ‘Outcomes comparison in the management of displaced femoral neck fractures among elderly patients: total hip arthroplasty versus bipolar hemiarthroplasty’, Vajira Medical Journal: Journal of Urban Medicine, 68(1), Article e266094. Available at: https://doi.org/10.62691/vmj.2024.266094 • Thakkar, S.C., Hasenboehler, E.A. and Thakkar, C.J. (2020) ‘Post-traumatic arthritis of the acetabulum’, In: Thakkar, S.C. and Hasenboehler, E.A. (eds.) Post-traumatic arthritis: Diagnosis, management and outcomes. Cham: Springer, pp. 111–133. Available at: https://doi.org/10.1007/978-3-030-50413-7_8 (Accessed: 23 March 2026). • Thurston, M., Walizai, T., Knipe, H., Gaillard, F. and Murphy, A. (2018) Acetabular fracture. Reference article, Radiopaedia.org. Available at: https://doi.org/10.53347/rID-59043 • Tigges, S. (2024) Garden IV femoral neck fracture. Case study, Radiopaedia.org. Available at: https://doi.org/10.53347/rID-187179 • Tosounidis, T., Aderinto, J. and Giannoudis, P.V. (2017) ‘Pipkin type-III fractures of the femoral head: Fix it or replace it?’, Injury, 48(11), pp. 2375–2378. Available at: https://doi.org/10.1016/j.injury.2017.10.002 • Tosson, M. (2016) Pipkin fracture – type IV. Case study, Radiopaedia.org. Available at: https://doi.org/10.53347/rID-50163

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• van Embden, D., Roukema, G.R., Rhemrev, S.J., Genelin, F. and Meylaerts, S.A.G. (2011) ‘The Pauwels classification for intracapsular hip fractures: Is it reliable?’, Injury, 42(11), pp. 1238–1240. Available at: https://doi.org/10.1016/j.injury.2010.11.053 • Varacallo, M., Luo, T.D. and Johanson, N.A. (2024) Total hip arthroplasty techniques. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK507864/ (Accessed: 20 March 2026). • Wang, S., Li, B., Zhang, Z., Yu, X., Li, Q. and Liu, L. (2021) ‘Early versus delayed hip reduction in the surgical treatment of femoral head fracture combined with posterior hip dislocation: a comparative study’, BMC Musculoskeletal Disorders, 22, Article 1057. Available at: https://doi.org/10.1186/s12891-021-04968-1 • Watts, E., Weatherford, B.C. and Taylor, B.C. (2025) Acetabular fractures. Available at: https://www.orthobullets.com/trauma/1034/acetabular-fractures (Accessed: 21 March 2026). • Wheeless, C.R. (n.d.) Seinsheimer’s classification of subtrochanteric fractures. Wheeless’ Textbook of Orthopaedics. Available at: https://www.wheelessonline.com/bones/seinsheimers-classification-of-subtrochanteric-frxs/ (Accessed: 18 March 2026). • Yamamoto, T., Kobayashi, Y. and Nonomiya, H. (2019) ‘Undisplaced femoral neck fractures need a closed reduction before internal fixation’, European Journal of Orthopaedic Surgery & Traumatology, 29(3), pp. 73–78. Available at: https://doi.org/10.1007/s00590-018-2281-0 • Yu, X., Zhao, D., Huang, S. and Wang, B. (2015) ‘Biodegradable magnesium screws and vascularized iliac grafting for displaced femoral neck fracture in young adults’, BMC Musculoskeletal Disorders, 16, Article 279. Available at: https://doi.org/10.1186/s12891-015-0790-0

3D CT Visualisation of Fracture Displacement

• Demonstrates three-dimensional fracture displacement and fragment orientation not fully appreciated on plain radiographs.

• Highlights spatial relationships between proximal and distal fragments, aiding surgical planning.

Subtrochanteric fracture with hip dislocation (3D CT reconstruction): (A) anterior view and (B) posterior view

Source

Total Hip Arthroplasty (THA)

• The femoral head and acetabulum are replaced with prosthetic components.
• Femoral stem inserts into the femoral shaft from the proximal neck region.
• Similarly to a hemiarthroplasty, the stem may be cemented on uncemented depending on bone quality and functional demands.
• Higher risk of dislocation compared to hemiarthroplasty.

Total hip arthroplasty (X-ray)

Source

Type III: Dislocation of the hip (unspecified direction) with femoral neck fracture

Type IIIA: Without fracture of the femoral head.Type IIIB: With fracture of the femoral head.

Type II: Complete, non-displaced fracture

• Intact trabecular alignment.

• Stable with low risk of displacement.

Sources

Cephalomedullary Nail

• A hollow cephalomedullary nail is inserted through the greater trochanter into the femoral shaft.
• A lag screw is inserted laterally through the nail into the femoral head.
• Preferred for unstable fractures (A2, A3).
• Provides high biomechanical stability.
• Resists deforming muscle forces.
• Minimally invasive with less soft tissue disruption than DHS.
• Allows earlier weight-bearing.
• Suitable for lateral wall compromise and reverse obliquity.

Cephalomedullary nail fixation (X-ray)

Source

Communition patterns and classification

• Better visualises comminution and fracture morphology compared to radiographs.

• Detects instability features (e.g. lateral wall involvement).

• Improves AO classification.

• Image A: Radiograph suggests a stable fracture pattern.

• B-C: CT and 3D imaging reveal comminution and instability.

• Classification changed from a stable to an unstable pattern.

Source

Displaced Subtrochanteric Fractures

• Most commonly seen subtrochanteric fracture pattern.

• Image A: Radiograph demonstrates a displaced transverse fracture with medial cortical beak and varus angulation.

• Image B: CT provides improved visualisation of fracture cortical involvement, and fragment displacement, aiding surgical planning.

Subtrochanteric femoral fracture: (A): Radiogaph and(B): CT

Source

3D CT Reconstruction

• 3D CT reconstruction provides clear visualisation of fracture geometry.

• Demonstrates spatial relationships between fracture fragments and the acetabulum.

• Allows accurate classification using the Judet–Letournel system.

• Also allows detection of complex fracture patterns not fully described by the Judet–Letournel classification.

• Supports surgical planning by defining fracture configuration guiding surgical approach.

Three-column acetabular fracture patterns on 3D CT: (A) with a posterosuperior roof fragment, (B) with a horizontally separated roof fragment.

Source

Type I: Incomplete (valgus impacted) fracture.

• Stable fracture with low risk of displacement.

Sources

Dynamic Hip Screw (DHS)

• Preferred for stable fractures (A1).
• Extramedullary fixation (plate + screw).
• Allows controlled fracture compression due to sliding mechanism.

• Requires intact lateral wall.
• Less suitable for unstable patterns (A2 & A3) due to risk of failure).

Dynamic Hip Screw Fixation (X-ray)

Source

Rehabilitation

• Early mobilisation is strongly recommended, ideally within 24–48 hours post-surgery.
• Includes basic functional tasks: bed mobility, sit-to-stand, and assisted walking.
• Weight-bearing is encouraged unless contraindicated by the surgeon.
• Physiotherapy is essential to restore mobility, strength, and independence.
• Early mobilisation is associated with improved functional recovery and discharge outcomes.
• Reduces complications of immobility (e.g. DVT, pneumonia, pressure ulcers, delirium).

Total Hip Arthroplasty

• Used in elderly patients with severe comminution or poor bone quality.
• Often combined with fixation (plates and screws) to stabilise the acetabulum.
• Indicated in failed ORIF or post-traumatic osteoarthritis.
• Facilitates early mobilisation.

Total hip arthroplasty of the left hip following acetabular fracture (X-ray)

Source

Post-traumatic Osteoarthritis

• Degeneration of the joint following previous injury.
• Caused by cartilage damage and joint incongruity after fracture.
• Presents with joint space narrowing, osteophyte formation, and sclerosis.
• Often localised and asymmetric compared to primary osteoarthritis.

(A) Normal hip joint, (B) osteoarthritic changes with joint space narrowing and osteophytes (bone spurs)

Source

Functional Impact

Younger patients

• Better functional recovery compared to elderly patients, but deficits may persist.
• Some require walking aids or experience ongoing pain post-injury.

• Return to full pre-injury function is not guaranteed.

Older patients

• Significant long-term functional decline following hip fracture.
• Reduced mobility and increased dependence on walking aids.
• Reduced likelihood of returning to independent living.
• Decreased physical quality of life and increased dependency.

Psychosocial Impact

• Reduced participation in daily, social, and recreational activities is associated with negative psychological outcomes.
• Social support is associated with improved functional recovery including greater participation in activities and improved mobility.

Dynamic Hip Screw (DHS)

• Hollow lag screw inserted through the lateral femoral cortex and femoral neck over a gude pin.
• Side plate is placed over the lag screw shaft and is fixed to the femur will self-tapping screws.
• Lag screw can slide within the plate, allowing controlled compression across the fracture to promote healing.
• Lateral end of the screw may become more prominent due to sliding at the fracture heals.
• Requires dissection of vastus lateralis.

Dynamic Hip Screw Fixation (X-ray)

Source

Type I: Nondisplaced or minimally displaced (< 2 mm) fracture fragments.

• Typically low-energy injury.

• Usually managed conservatively or with simple fixation.

• Image A : incomplete fracture
• Image B: complete fracture

Source

Headless Compression Screws

• Provides interfragmentary compression to promote stable fracture healing.
• Inserted perpendicular to the fracture line.
• Headless design allows the screw to be burried beneath the articular surface.
• Minimises cartilage damage and joint irritation.

Headless compression screw fixation (X-ray)

Source

Fracture Comminution

• CT clearly demonstrates fracture comminution, including small intra-articular fragments.

• Fragmentation is often underestimated or not visible on plain radiographs.

• Identification of comminution is important for fracture classification and management.

Axial CT showing omminuted fracture of the antreior column (arrows)

Source

31A1: Femur, proximal end segment, trochanteric region, simple pertrochanteric fracture

• 31A1.1: Isolated single trochanter fracture

• 31A1.2 Two-part fracture

• 31A1.3 Lateral wall intact (>20.5 mm) fracture

Source

T-shaped Fracture

• Combines transverse + vertical fracture pattern.

• Produces multiplanar instability.

Source

Pauwels Classification: CT vs X-ray

• CT provides more accurate measurement of the Pauwels angle than plain X-ray.

• X-ray measurements may overestimate or underestimate due to projectional distortion and patient positioning.

• Image A (CT) provides a more accurate measurement of the Pauwels angle.

• Image B (X-ray) demonstrates a larger measured Pauwels angle in the same patient.

Source

Fracture of Both Columns

• Entire acetabulum detached from axial skeleton.

• Characteristic “floating acetabulum” appearance.

Source

Cannulated Screws

• Hollow screws placed over guide pins.
• Typically 2-3 screws are used.
• Inserted through the lateral femoral cortex below the greater trochanter.
• Extend across the femoral neck fracture.
• May be fully or partially threaded.
• Also used in various other fixation systems.

Cannulated screw fixation of a femoral neck (X-ray)

Source

Transverse + Posterior Wall Fracture

• Most common associated fracture.

• Associated with posterior hip dislocation and joint instability.

Source

Type IV: Completely displaced fracture

• No cortical contact

• High risk of avascular necrosis (AVN) due to vascular disruption.

Sources

Type II: Femoral head fracture superior (proximal) to fovea.

• Involves weight-bearing surface with relatively worse functional outcomes.

Sources

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Type V: Central fracture-dislocation of the hip with femoral head fracture

• High-energy mechanism (e.g. dashboard injury).

• Femoral head displaced medially through acetabulum.

Type IV

High-energy Trauma

• Direct high-impact force applied to the hip.
• e.g. Contact sports or pedestrian–vehicle impacts.

• Large force applied over a short time.
• Often results in complex or displaced fractures.
• May be associated with multiple injuries.

Malunion with DHS

• Fracture heals in an abnormal position (typically varus alignment).
• Caused by inadequate reduction or loss of fixation stability.
• Results in altered biomechanics and increased bending forces.
• Leads to limb shortening and impaired function.

• May require corrective surgery (e.g. valgus osteotomy or DHS correction).
• Rotaional malunion may also occur.

Malunion with DHS (X-ray)

Source

Cephalomedullary Nails

• Standard subtrochanteric fracture treatment.
• Provides high biomechanical stability.
• Effective against deforming muscle forces.

• Minimally invasive fixation, potentially lowering blood loss compared to DHS.

• Allows earlier weight-bearing compared to DHS.
• Suitable for lateral wall compromise and reverse obliquity.

Cephalomedullary nail fixation (X-ray)

Source

Percutaneous Screw Fixation

• Percutaneous screw fixation is a minimally invasive technique used in selected acetabular fractures.
• Typically indicated in non-displaced or minimally displaced fractures with maintained joint congruency.
• Allows stabilisation while preserving soft tissues and blood supply.
• Associated with reduced surgical morbidity compared to open approaches.

Percutaneous screw fixation of the right acetabulum (X-ray)

Source

Occult Stress Fractures

• Often not visible on initial X-ray.

• CT demonstrates subtle fracture lines.

• Early detection prevents displacement.

• Image A: suspected fracture on X-ray.

• Image B: CT-confirmed stress fracture.

Source

Open Reduction and Internal Fixation (ORIF)

• ORIF is a surgical procedure to realign and stabilise fractures.

• Internal fixation devices (e.g. screws or plates) are used to maintain alignment and stabilise the fracture.

• The type of fixation used depends on the fracture pattern, including location, orientation, and fragment size.

• ORIF is generally preferred in younger patients to preserve the joint, due to higher activity levels and better bone quality.

31A2: Femur, proximal end segment, trochanteric region, multifragmentary pertrochanteric, lateral wall incompetent (< 20.5 mm) fracture

31A2.2: With one intermediate fragment 31A2.3: With two or more intermediate fragments

Source

Heterotopic ossification (HO)

• Abnormal bone formation within soft tissues surrounding the hip.
• Common following high-energy trauma or surgical intervention.
• Can lead to pain, stiffness, and reduced range of motion.
• Visible on radiographs as ectopic bone around the joint (arrow).

Source

Roof Arc Angle

• Angle between a vertical line through the femoral head and a line from its centre to the fracture site.
• Measured on AP (A), iliac oblique (B) , and obturator oblique views (C).
• Assesses fracture stability using radiographic measurements.

• Angles outside the fracture zone indicate stability.
• >45° suggests preservation of the weight-bearing dome.

Source

Anterior Column Fracture

• Less common than posterior column fractures.

• Extends from iliac crest to pubis.

• May involve weight-bearing dome depending on fracture line.

Source

Complex Fracture Patterns

• CT defines complex fracture patterns involving anterior and posterior columns and walls.

• Improves understanding of fragment displacement.

• Multi-planar imaging improves visualisation of combined fracture components

Comminuted anterior column fracture with associated anterior wall component (white arrows) and posterior column fracture (black arrow)

Source

Type IV: Comminuted fracture with four or more fragments.

• Severe instability due to multiple fracture lines.

• Frequently associated with high-energy trauma.

Type IV

Type I: Femoral head fracture inferior (distal) to fovea

• Non-weight bearing region with relatively better prognosis.

Sources

Type II: Posterior hip dislocation, femoral head fracture (superomedial portion)

Type IIA: minimum/ no fracture of the acetabular rim and stable joint after reduction.Type IIB: significant acetabular fracture and hip joint instability after reduction.

31A3: Femur, proximal end segment, trochanteric region, intertrochanteric (reverse obliquity) fracture

31A3.1: Simple oblique fracture31A3.2: Simple transverse fracture 31A3.3: Wedge or multifragmentary fracture

Source

Type II: Femoral neck fracture 30-50°

• Moderate-angle fracture with mixed compressive and shear forces.

• Intermediate stability.

Source

Muscle Forces and Fracture Displacement

Anterior

Posterior

Strong muscle forces act on separate fragments, resulting in displacement if not adequately reduced and stabilised. These include:

• Iliopsoas: flexion
• Gluteus medius/minimus: abduction
• Adductors: medial displacement
• Lateral rotators: lateral rotation

Flexors: orange Abductors: green Adductors: pink Lateral rotators: blue

Dots indicate general regions of muscle attachment

Type IV: Type I or II fracture with associated acetabular fracture

• Complex injury with relatively poorer prognosis.

Sources

Type III: Femoral neck fracture >50°

• High-angle fracture with predominantly shear forces.

• Unstable with high risk of displacement and fixation failure.

Sources

Low-energy Trauma

• Often involves a fall from standing height.
• Direct impact onto the greater trochanter.
• Force is transmitted through the proximal femur.

• Typically results in intertrochanteric or femoral neck fractures.

Avascular Necrosis (AVN)

• Arterial supply to the femoral head predominantly enters via the neck region.
• Femoral neck fractures may damage the medial circumflex artery.
• Displaced fractures are associated with increased risk of vascular disruption.
• This distrupts blood flow to the femoral neck and head region.
• The lack of blood flow creates a risk of AVN.
• Risk of AVN may be reduced with arthroplasty in displaced fractures.

1a

2a

2b

1b

Femoral head structure and blood supply: (1a–b) normal trabecular bone and vascular supply, (2a–b) changes associated with avascular necrosis

Type V: Subtrochanteric fracture with extended fracture through greater trochanter

• Severe instability due to multiple fracture lines.

• Frequently associated with high-energy trauma.

Source

Transverse Fracture

• Separates superior and inferior acetabulum.

• Often leads to articular incongruity and instability.

Source

Axial-loading

• Axial force is transmitted proximally through the lower limb to the hip joint.
• Occurs during falls from height onto feet.

• Femoral head driven into the acetabulum.
• May result in acetabular or femoral head fractures.

Anterior Column + Posterior Hemitransverse (ACPHT) Fracture

• Common in elderly patients.

• Posterior component often non-displaced but destabilising.

Source

DHS Implant Failure: Screw breakage

• Failure of distal locking screws due to high bending stresses.

• Occurs when fracture instability causes the implant to become load-bearing, leading to excessive mechanical stress.
• Common in subtrochanteric fractures due to high bending forces.

• Associated with delayed union and nonunion.

• May require revision surgery with improved fixation.
• Plate breakage may also occur due to fatigue failure.

Screw breakage of a DHS fixation (X-ray)

Source

Type III: Partially displaced complete fracture

• Varus angulation and disrupted trabecular alignment.

• Unstable with increased risk of displacement and avascular necrosis (AVN).

Sources

Dynamic Over-valgus Correction

• Used in subtrochanteric nonunion or malunion with other fixations or failed fixations.
• Over-valgus correction realigns the proximal fragment to reducuce shear forces.
• Converts shear forces into compressive forces at the fracture site.
• Lag screw allows dynamic compression to promote fracture healing.
• Reduces risk of further varus collapse.

Dynamic Over-valgus Correction (X-ray)

Source

Sciatic Nerve Injury

• Most commonly associated with posterior acetabular fractures and dislocations.
• Caused by direct trauma, fracture fragments, or surgical intervention.
• May result in motor and sensory deficits (e.g. foot drop common fibular nerve involvement affecting dorsiflexors).
• Requires careful neurovascular assessment pre- and post-operatively.

Sciatic nerve in relation to the posterior acetabulum

Type IV: Anterior hip dislocation with femoral head fracture

Type IVA: Indentation type; depression of the superolateral surface of the femoral head.Type IVB: Transchondral type; osteocartilaginous shear fracture of the weight-bearing surface of the femoral head.

Type III: Three-part spiral fractures, often involving a "butterfly" fragment or a separate lesser trochanter fragment.

• Increased instability and risk of displacement due to deforming muscle forces.

IIIA: Lesser trochanter is part of the third fragment.IIIB: Third part is a butterfly fragment.

Source

Anterior Wall Fracture

• Less common than posterior wall fractures.

• Often due to low-energy trauma in older patients.

• Typically affects anterior joint stability.

Source

Hemiarthroplasty

• Prosthetic replacement of the femoral head with preservation of the acetabulum.
• Femoral stem inserts into the femoral shaft from the proximal neck region.

• The stem may be cemented, which is recommended for poorer bone quality or lower functional demands.
• Uncemented stems are used for more active patients with good bone quality, allowing bone to grow into the porous implant surface.
• May lead to acetabular erosion.

Hemiarthroplasty (X-ray)

Source

Dashboard Injury

• Knee strikes the dashboard during a road traffic collision.
• Force is transmitted proximally along the femoral shaft.
• Femoral head is driven into the acetabulum.
• Often associated with posterior hip dislocation and/or femoral head fracture.

Type I: Femoral neck fracture <30°

• Low-angle fracture with predominantly compressive forces.

• Stable with favourable healing potential.

Sources

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Type I: Posterior hip dislocation, femoral head fracture (inferomedial portion)

• Type IA: minimum/ no fracture of the acetabular rim and stable hip joint after reduction.

• Type IB: significant acetabular rim fracture and hip joint instability after reduction.

Occult Intertrochanteric Fractures

• Occult intertrochanteric fractures may not be visible on plain radiographs, particularly when non-displaced.

• Cortical outlines may appear intact on X-ray despite underlying trabecular fracture.

• CT can detect subtle fracture lines not evident on initial radiographic assessment.

Intertrochanteric fracture of the proximal femur: (A) occult on radiograph, (B) demonstraed on CT (arrows)

Source

Posterior Column + Posterior Wall Fracture

• Severe posterior injury pattern, often with associated injuries.

• Associated with high-energy trauma and instability.

Posterior column + posterior wall fracture

Total Hip Arthroplasty

• The femoral head and acetabulum are replaced with prosthetic components.
• Femoral stem inserts into the femoral shaft from the proximal neck region.
• Similarly to a hemiarthroplasty, the stem may be cemented or uncemented depending on bone quality and functional demands.
• Higher risk of dislocation compared to hemiarthroplasty.

Total hip arthroplasty (X-ray)

Source

Intra-articular Femoral Head Fragments

• CT detects intra-articular fracture fragments not clearly visible on radiographs.

• Important for assessing joint congruity and articular surface involvement.

• Presence of fragments may require surgical removal or fixation.

Axial CT demonstrating intra-articular femoral head fragment (circled)

Source

Type II: Two-part fractures.

• Variable stability

IIA: Transverse fracture.IIB: Spiral fracture with the lesser trochanter attached to the proximal fragment. IIC: Spiral fracture with the lesser trochanter attached to the distal fragment.

Source

Posterior Wall Fracture

• Most common acetabular fracture type.

• Frequently associated with posterior hip dislocation.

Source

Screw-cut out Implant Failure

• Superior migration of the fixation screw into the joint.
• Increased risk with greater tip-apex distance (>25mm).
• Associated with unstable frature patterns or poor lateral wall support.
• More likely in weaker bone.
• Younger patients often require corrective surgery with a cephalomedullary nail.
• Older patints often require arthroplasty following failure.

Screw-cut out implant failure (X-ray)

Source

Hemiarthroplasty

• Prosthetic replacement of the femoral head with preservation of the acetabulum.
• Femoral stem inserts into the femoral shaft from the proximal neck region.

• Stem may be cemented which is recommended for poorer bone quality or lower functional demands.
• Uncemented stems are recommended for more active patients with healthy bone which grows into the porous surface of the implant, providing stability.
• May lead to acetabular erosion.

Hemiarthroplasty (X-ray)

Source

Posterior Column Fracture

• Disrupts weight-bearing axis of the acetabulum.

• May result in instability of the entire hemipelvis.

Source

Type III: Type I or II fracture with associated femoral neck fracture

• High risk of AVN due to vascular disruption.

• The axial CT scan shows posterior dislocation of an intercalary fragment of the femoral neck with part of the head attached.

Sources

Buttress Plates

• Pre-countoured buttress plates are used to support and stabilise acetabular fracture fragments.
• Prevent displacement of fragments under load, particularly in the weight-bearing dome.
• Commonly used in posterior wall and column fractures.
• Restore articular congruency by maintaining reduction of the acetabulum.

Buttress plate fixation of the acetabulum (left hip) (X-ray)

Source

AO/OTA 31-A3 Implant Failure

• Fracture line converts compressive forces into shear forces.
• Loss of lateral wall support leads to instability and collapse.
• High risk of fixation failure (varus collapse, cut-out, implant breakage).
• Dynamic hip screw (DHS) performs poorly due to inability to resist shear.
• Cephalomedullary nails are preferred but failure can still occur.
• Failure is often related to fracture instability and poor reduction rather than implant alone.

Implant Failure in an unstable intertrochanteric fracture (X-ray)

Source

Distal Fragment Displacement and Rotation

• CT allows accurate assessment of fracture orientation in multiple planes.

• Axial CT imaging can demonstrate the direction of fracture displacement.

• This is difficult to assess on plain radiographs.

Axial CT demonstrating displacement of the distal femoral fragment with rotational malalignment.

Source

Associated Acetabular Fractures

• Identifies associated acetabular fractures that may be occult on plain radiographs.

• Defines acetabular fracture pattern and extent.

• Assesses joint congruity and articular surface disruption.

Axial CT demonstrating intra-articular femoral head fragment (arrow) with associated acetabular fracture (circled)

Source