Hip Fracture on X-ray: Imaging Findings

Hip fractures are divided anatomically into femoral neck fractures and intertrochanteric or subtrochanteric fractures. Femoral neck fractures are further classified by the Garden classification (stages I–IV based on displacement) or the Pauwels classification (types I–III based on fracture line angle). Displacement is the primary driver of treatment: non-displaced femoral neck fractures (Garden I–II) in physiologically young patients are managed with internal fixation using cannulated screws or dynamic hip screws, whereas displaced fractures carry high avascular necrosis and non-union rates, prompting hemiarthroplasty or total hip arthroplasty in most patients over 65. Intertrochanteric fractures, which have a more robust blood supply, are almost universally treated with fixation using a sliding hip screw or intramedullary nail.

A meta-analysis estimated CT sensitivity at 94% for occult proximal femoral fractures. Persistent clinical concern after a normal CT should prompt MRI.

Evidence consistently shows that surgical fixation or arthroplasty performed within 24 to 48 hours of admission is associated with lower rates of mortality, pulmonary embolism, pressure ulcers, and pneumonia compared with delayed surgery. Prolonged bed rest in elderly patients accelerates deconditioning and increases thromboembolic risk despite anticoagulation. Medical optimization — addressing anemia, anticoagulant reversal, cardiac evaluation, and electrolyte correction — should proceed rapidly in parallel with surgical planning rather than serially. Hip fracture programs with dedicated pathways targeting surgery within 24 hours have demonstrated meaningful reductions in 30-day and 1-year mortality across multiple health systems.