306

Imaging of Traumatic Injuries to the Hip

Jason W. Stephenson, MD1 Kirkland W. Davis, MD1

1 Clinical Science Center, University of Wisconsin School of Medicine Address for correspondence Jason W. Stephenson, MD, Department
and Public Health, Madison, Wisconsin of Radiology, Clinical Science Center, University of Wisconsin School of
Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792-
Semin Musculoskelet Radiol 2013;17:306–315. 3252 (e-mail: [email protected]).

Abstract Traumatic injuries of the hip are an increasingly common cause of morbidity and
mortality. These injuries can be grouped into fairly discrete patterns including femoral
head fractures and hip dislocations, femoral neck fractures, greater trochanteric

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fractures, intertrochanteric fractures, subtrochanteric fractures, and soft tissue injuries.
For each of these entities, specific features provide helpful diagnostic, prognostic, and
therapeutic information. Femoral head fractures and hip dislocations commonly occur
in combination. Fractures of the femoral head confer an increased risk of avascular
necrosis of the femoral head. Rare variations of hip dislocations exist including an
irreducible posterior dislocation and multiple varieties of anterior dislocation. Femoral
neck fractures, which can occur in younger individuals during high-energy trauma and
occur with far greater frequency in older osteoporotic individuals with low-energy
trauma, are commonly encountered radiographically but can also be radiographically
occult. Similarly, greater trochanter fractures have a high frequency of radiographically
occult distal extension. As is the case with many other femur fracture types, inter-
Keywords trochanteric and subtrochanteric fractures are less stable and more prone to developing
► hip nonunion the more comminuted and extensive they are. All of these injury patterns are
► fracture frequently encountered in the emergency setting. The ability to distinguish between
► trauma different types of injury and the knowledge of key discriminating and prognostic
► dislocation features are a must for the interpreting radiologist.

Hip trauma is extremely common, predominantly due to the In this review, we discuss the acute traumatic injuries to
remarkable frequency of falls and motor vehicle collisions. the region of the hip with specific emphasis on dislocation,
Injuries in this region occur either as a result of direct impact fractures, and selected soft tissue injuries. The mechanisms of
to the hip and pelvis or from an impact to the lower extremity injury and pathophysiology of each of these injury patterns,
that is transmitted to the hip indirectly. Either way, the hip is the imaging methods that are most effective in diagnosing
vulnerable during high-energy trauma as would be sustained these injuries, and the imaging features that have the most
during an automobile collision or fall from height. Individuals useful diagnostic, prognostic, and therapeutic value are pre-
with poor bone quality are also at risk during lower energy sented. Also, when appropriate, we discuss the most widely
traumatic injuries such as a fall from standing or a fall out of bed. accepted classification schemes and their value in the man-
The initial trauma survey often reveals the possibility of an agement of patients with these injuries.
injury to the hip. In addition, traumatic injuries about the hip are
also often discovered on trauma screening radiographs, during
Imaging of Hip Trauma
imaging of adjacent injured body parts, or on body computed
tomography examinations performed to assess for traumatic Radiographs
injury to the abdominopelvic viscera. The accurate detection of Radiographs are the most important tool in the imaging
hip injuries is important in reducing the patient’s risk of arsenal when evaluating the traumatized patient. They are
developing remote complications including posttraumatic oste- fast, widely available, and can be performed portably in the
oarthritis, fracture nonunion, or femoral head avascular necrosis. trauma bay. These studies are frequently used to detect acute

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 Imaging of Traumatic Injuries to the Hip Stephenson and Davis 307

fractures and malalignment. It should be noted, however, that

there is increasing evidence that radiographs show limited
sensitivity for fracture in patients with hip and pelvis pain in
the emergency setting.1
Imaging of the hip region usually begins with an ante-
roposterior (AP) radiograph of the pelvis (►Fig. 1). This is
provides an excellent snapshot of the positioning of the
femoral head with respect to the acetabulum but also in-
cludes the contralateral hip for comparison and allows for
evaluation of the integrity of the bones of the pelvic ring and
acetabula.1
In patients for whom there is specific concern for hip
fracture or a known hip fracture, dedicated hip radiographs
are also performed. This includes an AP view and, at least, a

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cross-table lateral view of the affected hip. Frog-leg lateral
views of the hip should be avoided in the setting of trauma due
to the possibility of displacing any existing fracture fragments
that may, among other things, increase the risk of osteonec-
rosis of the femoral head. Dedicated AP and lateral views of the
ipsilateral femur can be performed in combination with hip
radiographs to further evaluate proximal femur fracture pat-
terns and to detect additional areas of fracture extension.
These imaging strategies allow for adequate surveillance of Figure 2 The different regions of the proximal femur. These ana-
the anatomic zones of the proximal femur (►Fig. 2). tomical zones are the basis for the subclassification of proximal femur
In patients with known or suspected hip dislocation, a fractures.
three-view examination of the pelvis can be performed to
better evaluate the acetabular walls and columns. Such a
three-view examination includes the AP view and bilateral views are critical in achieving adequate visualization of the
45-degree oblique (Judet) views of the pelvis (►Fig. 3). These anterior and posterior acetabular walls, iliac wings, and
obturator foramina as well as the anterior and posterior
acetabular columns. However, many trauma centers have
eliminated Judet views as part of the initial survey for
dislocations and progress from AP and lateral views to a
computed tomography (CT) examination with or without
three-dimensional (3D) reconstructions.

Computed Tomography
Noncontrast CT of the hips and pelvis are helpful in identify-
ing and further characterizing fractures and dislocations in
the pelvis and hips. Dedicated CT of the bony pelvis usually
involves acquisition of thinly collimated (<1 mm) contiguous
images of the entire pelvis extending from just above the iliac
crests, down through the proximal femoral shafts below the
level of the lesser trochanters. These images are processed
with both bone and soft tissue reconstruction kernels dis-
played in separate axial series. The bone kernel images are
reformatted in the coronal and sagittal planes to increase the
Figure 1 An anteroposterior (AP) radiograph of the pelvis obtained on conspicuity of fracture lines and subtle malalignment, as well
a pedestrian stuck by an automobile. The AP view of the entire pelvis as provide more comprehensive depiction of the injuries for
allows for side-by-side comparison of both hips and both acetabula.
the treating team. The images are excellent in evaluating the
Important acetabular landmarks highlighted on the left side include
the ilioischial line (red arrows) identifying the region of the posterior
fracture extent, assessing for additional fracture defects,
column, the iliopectineal line (black arrows) identifying the region of identifying and characterizing the extent of articular involve-
the anterior column, the “teardrop” (black line), which represents a ment, assessing for intra-articular fracture fragments, and
confluence of shadows along the inferomedial aspect of the acetab- evaluating alignment. Some surgeons also request that
ulum, and the anterior (blue line) and posterior (green line) acetabular
3D volume-rendered images be created to assist operative
walls. The sourcil (black asterisk) represents the cortex of the ace-
tabular roof seen on end. Important landmarks of the proximal femur
planning further.
are highlighted on the right and include the greater (gt) and lesser (lt) CT images of the pelvis are often reconstructed from CT
trochanters, the femoral neck (fn), and calcar (black arrowheads). data previously acquired during CT of the abdomen and

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308 Imaging of Traumatic Injuries to the Hip Stephenson and Davis

Figure 3 Bilateral Judet views of the pelvis show the displaced right posterior acetabular wall fracture fragment (white arrow) and displaced
femoral head fracture fragment to advantage. (a) The iliac (ipsilateral) oblique Judet view allows excellent visualization of the ipsilateral iliac wing
(iw), ilioischial line (white arrowheads), and anterior acetabular wall (empty arrows). This view also best demonstrates the inferiorly displaced
femoral head fracture fragment (black arrow). (b) The obturator (contralateral) oblique view best demonstrates the ipsilateral obturator foramen

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(of), posterior acetabular wall (white arrow), and iliopectineal line (black arrowheads). (c, d) Coronal reformatted noncontrast computed
tomography images confirm displaced femoral head (c, black arrow) and posterior acetabular wall (d, white arrow) fractures.

pelvis. These studies are often performed with a larger slice posterior.6 Femoral head fractures are also associated with
thickness (>1 mm) and are frequently performed after the acetabulum fractures, particularly those that involve the
intravenous administration of iodinated contrast. Although posterior wall. This is not surprising, however, because
these factors can lead to a decrease in the quality of bone and both posterior dislocation and posterior wall fractures result
3D reconstructions, they are often sufficient for the purposes from similar mechanisms of injury and, as indicated, often
of the acute trauma evaluation. The benefit of performing occur in combination.6–11
such reconstructions is that, when performed as a substitute Anterior hip dislocations are much rarer and occur when
for a dedicated CT of the hips and bony pelvis, the total an axial load is delivered to an abducted and externally
radiation dose to the patient is less. It should be noted that rotated hip. Typically, if the hip is also extended, this mecha-
this benefit is much more profound in younger patients nism will result in an anterosuperior hip dislocation (iliac or
whose fractures are likely to be more conspicuous on all pubic). If the hip is flexed, this results in an anteroinferior hip
imaging modalities. dislocation (obturator) (►Fig. 4). In either case, associated
trough-like impaction fracture of the lateral and posterolat-
MR Imaging eral periphery of the femoral head, so-called indentation
MRI has a limited role in the evaluation of acute hip trauma. fractures, or a traumatic osteochondral fracture may result.
This is, in part, because of its limited availability and long scan These are usually visible radiographically.6,8
times that make it a poor choice in the acutely injured patient Fractures of the femoral head are of particular concern
who requires rapid assessment and potentially other imme- because they represent a combination of direct and indirect
diate lifesaving measures. Noncontrast MRI, however, is the factors that can ultimately lead to the development of
imaging method of choice in otherwise stable patients for
whom there is concern for radiographically occult fractures.
This is especially true in the osteoporotic patient in whom a
femoral neck fracture is suspected. When time is of the
essence, a limited MR scan can be used; one option is to
perform only coronal T1-weighted and T2-weighted or short
tau inversion recovery sequences, which will allow a gross
assessment for fractures of the femoral neck and whole pelvis
and will depict muscle injuries that often mimic hip fractures
clinically.2–5

Femoral Head Dislocation and Fracture

Mechanism and Pathophysiology
Femoral head fractures are one of two types of intracapsular
proximal femur fractures, with the other being femoral neck
fractures. Femoral head fractures occur almost exclusively in
the setting of indirect trauma to the hip such as that sustained
when the knees contact the dashboard with the hip flexed Figure 4 Anteroposterior radiograph of the pelvis demonstrates
during a motor vehicle collision. Accordingly, these fractures anteroinferior dislocation of the left hip without associated femoral
are seen in the setting of hip dislocation, 90% of which are head or acetabular fracture.

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 Imaging of Traumatic Injuries to the Hip Stephenson and Davis 309

secondary osteoarthritis and place the patient at risk for the there is an associated sagittally oriented fracture in the
development of avascular necrosis and/or fracture nonunion. femoral head. This variation also demonstrates slight flexion
These fractures often occur in a young patient population for and superior positioning of the femur but with neutral
whom loss of function and further medical and surgical rotation and minimal, if any, adduction. This constellation
intervention may impose significant problems. of findings has been associated by multiple authors with an
irreducible variant of posterior hip dislocation for which
Classification closed reduction is contraindicated.13,14 That is to say, iden-
Numerous classification schemes for femoral head fractures tification of this pattern on initial imaging can be useful in
have been described in the literature. Typically these classify guiding clinical management of these patients and, specifi-
dislocations based on the generally accepted notion that cally, in preventing additional soft tissue injury or iatrogenic
associated fractures of the proximal femur and acetabulum fracture during unsuccessful reduction attempts.
portend a worse prognosis due to increased risk of avascular CT imaging is routinely used for additional classification of
necrosis of the femoral head, nonunion, and posttraumatic femoral head and acetabular fracture patterns, to assess for
osteoarthritis. The association between posterior hip disloca- additional fractures and fragments not visible radiographi-

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tion and femoral head fracture was first described in a case cally, as well as to identify the presence of entrapped intra-
report by Birkett in 18969 and classified by Pipkin in 195710 articular fragments visualize associated soft tissue injury, and
(►Fig. 5) in a system that remains in wide usage today. to identify the cause of an unreducible dislocation.
With regard to soft tissue injuries, 11% of posterior hip
Imaging dislocations result in injury to the sciatic nerve or one of its
On an AP view of a posterior hip dislocation, the proximal components.6 Direct signs of impingement on CT are gener-
femur is slightly flexed, adducted, and internally rotated with ally thought to include deviation of the sciatic nerve by
the femoral head superiorly positioned with respect to the hematoma, fracture fragments, or the dislocated femoral
acetabulum (►Fig. 3). In the much less common anterior head, although these have not been rigorously established
dislocation, the femoral head may lie superior or inferior in the literature. The sciatic nerve is often difficult to visualize
(►Fig. 4) to the acetabulum. Whether anterior or posterior, on CT due to the presence of hematoma and swelling at the
the acetabulum and femoral head must be carefully inspected level of the hip joint.
on radiographs to exclude associated fractures. If present, the
position of the fractures with respect to the fovea capitis and
Femoral Neck Fractures
the presence of additional fractures of the pelvic ring, acetab-
ulum, or proximal femur should be mentioned.10,12,13 Mechanism and Pathophysiology
Careful analysis of radiographs can also reveal a less The second of two types of intracapsular proximal femur
common variation of posterior hip dislocation in which the fractures are femoral neck fractures. These can be grouped
posterior acetabulum is intact, the femoral head and neck are into two broad categories based on the quality of the patient’s
closely opposed to the posterosuperior acetabular rim, and underlying bone stock and the mechanism of injury.15
The more common are low-energy femoral neck fractures
that occur in older patients with osteoporosis. These low-
energy injuries account for 90% of femoral neck fractures
and are sustained during a fall from a standing height, a
mechanism that would not be expected to cause a fracture in
a patient with normal bone mineralization. As a result, these
fragility femoral neck fractures have an incidence that in-
creases with patient age, occur almost exclusively in patients
>50 years of age, and occur more frequently in populations
with a predilection for osteoporosis including women and
whites.16–18
High-energy injuries make up the minority of femoral
neck fractures. These are more likely to occur in young
individuals who suffer traumatic high-energy axial loading
of the femur that would occur during a motor vehicle collision
or fall from great height. As a result, the prevalence of serious
associated neurologic, thoracic, and abdominopelvic injuries
Figure 5 Pipkin classification of femoral head fractures. 10 Type I injury are high as is the prevalence of comminution, displacement,
is a fracture of the femoral head below the level of the fovea capitis and and associated musculoskeletal injury.
the site of entry of the artery of the ligamentum teres. Type II is a
femoral head fracture that extends above the fovea. A type III defect
Classification
consists of either type I or II injuries with a concomitant femoral neck
fracture. Finally, a type IV fracture is one of any or a combination of the
The classification of femoral neck fractures has been contro-
preceding fracture types in addition to an associated ipsilateral versial and many different schema have been described in the
acetabular fracture. literature.7,19–22 Perhaps the most widely accepted system is

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310 Imaging of Traumatic Injuries to the Hip Stephenson and Davis

likely to go on to nonunion and or femoral head avascular

necrosis (“unstable”)21 (►Fig. 6). Other classification systems
have incorporated the concept of fracture geometry that was
used as a surrogate for healing prognosis. Accordingly, more
vertically oriented fractures complexes were more likely to
displace with weightbearing and go on to nonunion com-
pared with more horizontally oriented fracture defects.7,20 It
should be noted that there is compelling data arguing for and
against the clinical utility of each of these classification
systems.7,19–22

Imaging
The vast majority of these fractures are evident on initial
radiographs23 (►Fig. 7). Dedicated AP and cross-table lateral

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views of the affected hip and a well-positioned AP view of the
pelvis are sufficient to make the diagnosis. A major pitfall in
the radiographic evaluation of these injuries is excess exter-
nal rotation of the femora on the AP view. This results in
foreshortening of the femoral neck and superimposition of
the femoral neck and greater trochanter shadows, thereby
Figure 6 Consolidated Garden classification. The Garden classifica- hindering visualization. Slight internal rotation of the proxi-
tion system describes the pattern of femoral neck fractures. Type I mal femur is required to profile the femoral neck appropri-
represents an incomplete fracture deformity with mild impaction of
ately. A second major pitfall is the presence of osteoarthritis in
nondisplaced fracture fragments. Type II is a complete nondisplaced
fracture through the femoral neck. Type III is a partially displaced the affected hip that can create a circumferential rim of
fracture that often results in varus positioning of the proximal femur. osteophytes around the femoral head articular surface that
Type IV is a complete fracture that has displaced completely leading to can be mistaken for a subcapital femoral neck fracture.
“complete loss of engagement” of fracture fragments. Similarly, fractures that should be evident radiographically
can be missed when they are misperceived as a rim of
osteophytes (►Fig. 8).
the Garden classification that groups these fractures based on
the completeness of the fracture defect and degree of dis- Radiographically Occult Fractures
placement of fragments19,21 (►Fig. 6). More recent work has Approximately 10% of proximal femur fractures are radio-
shown that a grouping of the major Garden categories is graphically occult at the time of initial presentation.23 This is
helpful in dividing these injuries into categories that are likely particularly true for the low-energy injury category that is
to heal without complication (“stable”) and those that are less likely to be displaced and occurs on a background of

Figure 7 (a) Garden II fracture/stable fracture. Anteroposterior (AP) radiograph of the right hip demonstrates a minimally impacted complete
fracture through the subcapital region of the right proximal femur. Because these heal with a high rate of success, they are described as stable
injuries despite the fact that they typically require internal fixation. (b) Garden IV/unstable fracture. AP radiograph of the right hip demonstrates a
completely displaced femoral neck fracture with shortening of the femur, internal rotation of the distal femoral fragment, and little or no
engagement of the main femoral head and neck fragments.

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 Imaging of Traumatic Injuries to the Hip Stephenson and Davis 311

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Figure 8 (a) Anteroposterior hip radiograph in an 81-year-old woman with hip pain following a fall. A questionable sclerotic line along the superolateral
aspect of the femoral head–neck junction can easily be mistaken for a rim of osteophytes. A high level of clinical concern for fracture and questionable
radiographic abnormality both warranted MRI evaluation. T1-weighted image from a subsequent MRI (b) confirmed a Garden I fracture deformity.

osteoporosis; this makes the lucent fracture cleft or impaction Specifically, Feldman et al showed that 35 of 37 patients who
density much less conspicuous. It should be noted that these presented with radiographically apparent greater trochan-
same factors may limit the visibility of these fractures on CT. teric fractures had extension of the fracture beyond the
Multiple studies have demonstrated nearly 100% sensitiv- greater trochanter on follow-up MR examination, often re-
ity of MRI in the detection of these fractures.4,5,23 According- sulting in a change in patient management.25,26 Recognizing
ly, in patients who, despite the absence of a radiographically this, it is advisable to recommend MRI for patients presenting
apparent fracture, have decreased bone mineral density, for with apparently isolated greater trochanter fractures
whom there is high clinical concern for fracture and/or are (►Fig. 9).
unable to bear weight, emergent MRI should be
recommended.
Intertrochanteric Fractures
Imaging Evaluation
Greater Trochanteric Fractures
The radiographic evaluation of intertrochanteric fractures
Mechanism and Pathophysiology involves much more than simple identification of the fracture
Isolated greater trochanteric fractures occur due to direct defect. The presumed stability of the fracture pattern will
trauma or from osseous avulsion due to the forces exerted by determine whether or not the treating surgeon will perform
the gluteus minimus and medius tendons. In children, the an internal fixation and, if so, what device and approach are
avulsive mechanism is most common, whereas for adults, indicated. Following the initial AP and lateral views of the hip
direct traumatic fractures predominate.24 In either case the and whole femur, an initial closed reduction may be per-
pull of the external rotators of the hip and the gluteal muscles formed using traction, necessitating a series of traction
can impart a superior displacing force. Such displacement can radiographs until appropriate reduction is achieved.24
make these fractures obvious radiographically. Otherwise,
without displacement these fractures can be difficult or Classification and Imaging
impossible to appreciate on radiographs.16,22,23,25,26 It is Many different methods of classifying intertrochanteric frac-
helpful to keep in mind that fractures that are displaced tures have been devised. To varying degrees, these schemes
initially <1 cm typically do not displace further and can be consider anatomical relationships, prognostic significance,
managed nonoperatively.24 and factors related to surgical fixation and instrumentation
choice.
Imaging The radiologist’s role does not necessarily include intimate
Meticulous radiographic technique is required, especially on knowledge with the nuances of each of these classification
AP views, to identify these fractures if they are nondisplaced. schemes. This role does, however, require knowledge of the
Excessive external rotation of the ipsilateral hip on the AP key findings that distinguish the different stages of these
views of the pelvis and hips will result in poor profiling of the classification systems as well as an overall understanding of
greater trochanter, hindering detection of a fracture. their relative importance.
Multiple studies have shown that radiographs can under- Each classification in some way addresses the issue of
estimate the proximal femur fracture extent in patients with stability. Generally speaking, stability, as used to describe
a presumed “isolated” greater trochanter fracture deformity. intertrochanteric fractures, is a function of how likely the

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312 Imaging of Traumatic Injuries to the Hip Stephenson and Davis

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Figure 9 (a) Anteroposterior radiograph of the left hip shows a minimally displaced fracture of the left greater trochanter (arrow). (b, c) Coronal
T1-weighted MR images performed emergently demonstrate the previously visible greater trochanteric fracture deformity (arrow) plus an
intertrochanteric extension (arrowheads) that was not visible radiographically.

fracture is to be anatomically reducible and how likely it is to

stay reduced. Comminution and disruption of the posterolat-
eral and lateral cortex of the greater trochanter and proximal
femoral shaft as well as the medial cortex of the lesser
trochanter, femoral arch, and proximal femoral shaft portend
less stability than the absence of these findings (►Fig. 10).
Posterior displacement of the proximal fragment with respect
to the distal fragment and an increased number of fracture
fragments also generally represent an unstable fracture. In all
of the situations just described, instability usually results in a
fracture that is likely to end up with excessive varus position-
ing of the proximal femur.7,24,27,28
Finally, a fracture that has a reverse obliquity pattern is a
fracture that traverses the intertrochanteric region perpen-
dicular to the intertrochanteric line. This represents a partic-
ularly unstable pattern regardless of the features previously
mentioned. This is because axial loading of fragments that
occurs during weightbearing results in inevitable medial
displacement of the main distal fragment regardless of the
other features of the fracture pattern.27–29 This pattern is also
notoriously poorly fixed with a dynamic (sliding) hip screw
device.28,29
As with any proximal femur fracture, displaced fractures
have higher rates of complications and fractures with intra-
capsular extension have higher rates of nonunion. These are
factors that must be considered during any imaging evalua-
tion and especially if cross-sectional studies, such as CT and
MRI, are performed because these may identify subtle fea-
tures of instability that may not be apparent on radio-
graphs.27,30 It should be noted, however, that unless there
is suspicion of extension into the femoral neck or specific
concern for other complicating factors, cross-sectional imag-
ing is usually not indicated for these patients. In short, the key Figure 10 (a) Anteroposterior radiograph of the left hip shows an
intertrochanteric fracture line (arrowheads) with posterolateral comminution
features to report include degree of comminution and pres-
(black arrow) and comminution in the region of the lesser trochanter (white
ence of separate lesser and greater trochanteric fragments, arrows). These fractures, when nondisplaced, can be difficult to appreciate
proximal extension into the intra-articular portion of the radiographically. (b) A crosstable lateral view of the left hip in the same patient
femur or distally into the diaphysis, and angulation and more easily demonstrates apex anterior angulation (black arrow)at the
displacement of the dominant fragments.24 fracture site that results from relative flexion of the proximal fragment.

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 Imaging of Traumatic Injuries to the Hip Stephenson and Davis 313

predilection. Specifically, these fractures occur in young

men and older women most commonly. As one would expect,
in the former group, these fractures result from high-energy
trauma, whereas lower energy trauma from falls and osteo-
porosis are implicated in the latter group. Statistically, most of
these fractures occur in the elderly population and make up
25% of all hip fractures.32,33

Classification
Key features of these fractures include the anatomical loca-
tion of major fracture lines, extent of comminution, and the
number and position of dominant fragments. Fractures that
pass through the piriformis fossa often require a different
surgical approach compared with fractures that do not.

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Comminution in the region of the lesser trochanter and
posteromedial cortex signifies a less stable pattern with a
propensity to displace.32
Distinction from intertrochanteric fractures can be chal-
lenging because there is overlap in the classification systems.
In addition, the age of the patient may influence surgeons to
consider subtrochanteric region fractures in young adults as
proximal shaft fractures versus hip fractures in elderly adults.
Figure 11 Russell-Taylor classification of subtrochanteric proximal Several different subtrochanteric fracture classification
femur fractures. Type I fractures involve a subtrochanteric fracture line
schemes have been described in the literature.7,32,33 These
without medial proximal femoral cortex/lesser trochanteric commi-
nution, and type II injuries represent subtrochanteric fracture lines
often highlight patterns with particularly poor prognostic
with medial proximal femoral cortex/lesser trochanteric comminution. features such as involvement of the lesser trochanter and
These two categories are further subdivided into type A fractures that medial and posterolateral cortical comminution. The most
do not have intertrochanteric extension and type B fractures that do. commonly used is currently the Russell-Taylor classification
(►Fig. 11) that has the benefit of conveying important
Subtrochanteric Fractures information regarding subsequent operative fixation.

Mechanism and Pathophysiology

Imaging Evaluation
The subtrochanteric region is subject to high mechanical In addition to standard radiographs of the pelvis and hip,
stress that results from a combination of weightbearing orthogonal AP and lateral views of the entire involved femur
load and the numerous nearby muscle insertions that exert are obtained. Proper positioning with these radiographs is
an angular deforming load.31 Subtrochanteric fractures usu- critical for several reasons. First, effective assessment of the
ally result in medial compression and lateral tension. lesser trochanter and posteromedial proximal femoral cortex
Subtrochanteric fractures generally demonstrate a bimod- is necessary. Also, effective screening of the femoral neck is
al distribution in the population with associated gender necessary to exclude a combination neck-shaft injury. With

Figure 12 (a) Anteroposterior radiograph of the right hip demonstrates an angulated and displaced subtrochanteric fracture of the proximal
right femur with a comminuted lesser trochanter component. Note that abduction and flexion of the proximal fragment results in poor
visualization of the femoral neck. (b) Follow-up noncontrast computed tomography (CT) coronal reformatted image shows radiographically occult
extension into the right femoral neck (arrow). In this case, CT evaluation results in a change of grade from IB to IIB.

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314 Imaging of Traumatic Injuries to the Hip Stephenson and Davis

Tendon injuries also may accompany these previously

described fracture patterns. These rarely require specific
imaging evaluation in the acute trauma setting, although
they can contribute to morbidity during rehabilitation and
subsequently.37 Nonemergent MRI or ultrasound is often
necessary for the definitive diagnosis of these defects.
Injuries that involve direct trauma to the hip region can
also result in a closed degloving injury, known as the Morel-
Lavallée lesion. This results from shearing disruption between
the deep fascia and subcutaneous fat that initially fills with
blood but subsequently organizes and ultimately contains
varying amounts of hemorrhagic debris, serous fluid, and/or
lymphatic fluid (►Fig. 13). Although these lesions classically
have been thought to be recalcitrant to therapeutic measures,

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a recent meta-analysis showed at least satisfactory results in
95% of patients who underwent surgery or percutaneous
sclerotherapy compared with nonoperative management.
These lesions are typically evident on MRI, CT, and
ultrasound.38,39

Figure 13 Morel-Lavallée lesion. Patient had a prior history of direct

trauma to the right hip with persistent right hip pain and palpable focal
Conclusion
soft tissue prominence over the right greater trochanter. (a) T1- Hip fractures are common in the setting of acute trauma.
weighted and (b) fat-suppressed T2-weighted images of the pelvis
Understanding the differences between them and the perti-
demonstrate a lenticular fluid signal collection centered at the junc-
tion between the subcutaneous fat and deep fascia without sur- nent diagnostic and prognostic features of each of these
rounding soft tissue edema or fatty effacement. This appearance is fracture patterns is critically important for the interpreting
typical for a chronic closed degloving injury, the so-called Morel- radiologist. Moreover, although radiographs continue to rep-
Lavallée lesion. resent the main imaging tool for diagnosis, CT and MRI also
have important well-defined roles in specific subpopulations.

regard to hip radiographs, this requires adequate external

rotation of the femur on AP views and an appropriately Acknowledgments
positioned cross-table lateral view. We would like to thank Drs. Kirkland Davis and Donna
Generally, cross-sectional imaging is not necessary for Blankenbaker for their kindness, understanding, and
these fractures unless complicating factors are suspected. mentorship.
Usually this means complex proximal extension (►Fig. 12),
in which case CT is used to further classify the fracture and
guide surgical planning. In addition, CT is particularly helpful
if there is suspicion for an associated concomitant radio- References
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