Acute Pelvis & Hip Trauma Imaging Diagnosis Part II

Hip Fractures

Garden Classification (above) helps with Dx and correct management of patients
M/C Fx are subcapital (80%)
Fxs differentiated as intra-capsular (high risk of AVN) & extra-capsular (lower risk of AVN)
Garden 1: incomplete undisplaced Fx typically impaction with valgus off-set of the head (15-20% AVN) patient able to ambulate
Garden 2: complete, undisplaced Fx (30% AVN)
Garden 3: complete, partially <50% displaced
Garden 4: complete, 100% displaced Fx, pt collapsed with entire LE in ER (below image)
Most osteoporotic Fx are intracapsular

Complete Displaced Femoral Neck Fracture Clinical Presentation

Imaging: Begins with X-radiography with Most Fxs

CT scanning may help with further delineation of Fx complexity/displacement and Dx of additional regional Fxs
MRI can be helpful if x-radiography fails to Dx fx
X-radiography pitfalls: some undisplaced Garden 1 & 2 Fxs may be missed d/t pre-existing DJD and osteophytes along the femoral head-neck junction that may overly the Fx line
Fx line is incomplete and too small/subtle especially if the study is read by non-radiologists
Incomplete Fxs if left untreated will not heal and likely to progress to complete Fxs

AP hip spot view: note valgus deformity of the head (above yellow arrow) with a small/subtle line of sclerosis in the sub-capital region representing Garden 1 Fx. MRI may help with Dx of subtle radiographic Fxs. If MRI contraindicated, Tc 99 radionuclide bone scan may help demonstrate high uptake of the radiopharmaceutical in Fx (below image)

Above – Tc99 Radionuclide Bone Scan Reveals Left Subcapital Femoral Neck Fx

Garden 2 complete undisplaced (above green arrows) Fx

AP hip: Garden 3 complete partially displaced Fx (above the first image)
AP pelvis: complete displaced Garden 4 Fx (above the second image)
Clinical pearls: in some cases of Garden 4 Fx, DDx may be difficult to differentiate from OSP vs. pathologic fx d/t to bone Mets of Multiple myeloma (MM)
Management: depends on patients age and activity level
Garden 3 & 4 require total hip arthroplasty in patients <85-y.o.
Garden 1 & 2 may be treated with closed reduction of fx and open capsule and 3-cannulated fixating screws
Pre-existing DJD may require total arthroplasty
Occasionally observation may be performed on patients who are not active and significant risks of surgery and depends on surgical centers

m/c Rx of Garden 1 & 2 undisplaced Fx with 3-screws. Screws proximity depends on the bone quality and Fx type

THA aka hip replacement: cemented THA with bone cement (above the first image) vs. non-cemented (biologic) that is used mostly in younger patients
2-types: metal on metal vs. metal on polyethylene
The femoral angle of the prosthesis should have slight valgus but never >140 degrees
The non-cemented component uses porous metal allowing the bone to integrate sometimes coating in bone cement from osteoconduction
THA has good outcome and prognosis
Occasionally cement failure, fractures, and infections may complicate this procedure

Supplemental Reading

Acute Pelvis & Hip Trauma

Dr. Alexander Jimenez ♛

Advanced Chiropractic & Wellness Authority ⚕ Healthcare Educator • Injury, Sciatica Specialist • 915-850-0900 📞

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Acute Pelvis & Hip Trauma Imaging Diagnosis Part II | El Paso, TX.