eMedicine Specialties > Sports Medicine > Hip

Femoral Neck Fracture: Differential Diagnoses & Workup

Author: Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Coauthor(s): Neil N Jasey, Jr, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey; Jennifer Solomon, MD, Staff Physician, Department On Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey
Contributor Information and Disclosures

Updated: Jan 28, 2009

Differential Diagnoses

Osteitis Pubis
Slipped Capital Femoral Epiphysis
Snapping Hip Syndrome

Other Problems to Be Considered

Acetabular labral tear
Avascular necrosis
Avulsion fracture about the pelvis
Hernia
Legg-Calve-Perthes Disease
Lymphadenopathy
Muscle strains
Myositis ossificans
Osteoarthritis
Ovarian cyst
Pain from the spine or back
Pelvic inflammatory disease
Pubic instability
Synovitis or capsulitis

Workup

Laboratory Studies

  • Laboratory studies generally are not necessary for the diagnosis of femoral neck fractures.

Imaging Studies

  • Plain radiographs
    • Plain radiographs have traditionally been ordered as the initial step in the workup of hip fractures. The main purpose of x-ray films is to rule out any obvious fractures and to determine the site and extent of the fracture. Plain radiographs have poor sensitivity. The presence of periosteal bone formation, sclerosis, callus, or a fracture line may indicate a stress fracture; however, a plain radiograph may appear normal in a patient with a femoral neck stress fracture, and radiographic changes may never appear.
    • Radiographs may show a fracture line on the superior aspect of the femoral neck, which is the location for tension fractures. Tension fractures must be distinguished from compression fractures, which, according to Devas9 and Fullerton and Snowdy,10 are usually located on the inferior aspect of the femoral neck.
    • The standard radiographic examination of the hip includes an anteroposterior view of the hip and pelvis and a cross-table lateral view. The frog-leg lateral view is poorly tolerated and may result in fracture displacement. If a femoral neck fracture is suggested, an internal rotation view of the hip may be helpful to identify nondisplaced or impacted fractures. If a hip fracture is suggested but not seen on standard x-ray films, a bone scan or magnetic resonance imaging (MRI) study should be performed.
  • Bone scanning
    • Bone scans can be helpful when a stress fracture, tumor, or infection is suggested. Bone scans are the most sensitive indicator of bone stress, but they have poor specificity. Shin et al reported that bone scans have a 68% positive predictive value.12 Bone scans are limited by relatively poor spatial resolution of the pertinent anatomy of the hip.
    • In the past, a bone scan was thought to be unreliable before 48-72 hours after a fracture; however, a study by Holder et al found a sensitivity of 93%, regardless of the time from injury.13
  • MRI
    • MRI has been shown to be accurate in the assessment of occult fractures and can be reliably performed within 24 hours of the injury; however, these studies are expensive.
    • With MRI, a stress fracture typically appears as a fracture line at the cortex surrounded by an intense zone of edema in the medullary cavity.
    • In a study by Quinn and McCarthy, T1-weighted MRI findings were found to be 100% sensitive in patients with equivocal radiographic findings.14 Shin et al showed that MRI findings are 100% sensitive, specific, and accurate in identifying a femoral neck fracture.12

More on Femoral Neck Fracture

Overview: Femoral Neck Fracture
Differential Diagnoses & Workup: Femoral Neck Fracture
Treatment & Medication: Femoral Neck Fracture
Follow-up: Femoral Neck Fracture
Multimedia: Femoral Neck Fracture
References
[ CLOSE WINDOW ]

References

  1. Plancher KD, Donshik JD. Femoral neck and ipsilateral neck and shaft fractures in the young adult. Orthop Clin North Am. Jul 1997;28(3):447-59. [Medline].

  2. Brukner P. Sports medicine. The tired athlete. Aust Fam Physician. Aug 1996;25(8):1283-8. [Medline].

  3. Koval KJ, Zuckerman JD. Hip fractures: I. Overview and evaluation and treatment of femoral-neck fractures. J Am Acad Orthop Surg. May 1994;2(3):141-149. [Medline].

  4. Joshi N, Pidemunt G, Carrera L, Navarro-Quilis A. Stress fracture of the femoral neck as a complication of total knee arthroplasty. J Arthroplasty. Apr 2005;20(3):392-5. [Medline].

  5. Volpin G, Hoerer D, Groisman G, Zaltzman S, Stein H. Stress fractures of the femoral neck following strenuous activity. J Orthop Trauma. 1990;4(4):394-8. [Medline].

  6. Zahger D, Abramovitz A, Zelikovsky L, Israel O, Israel P. Stress fractures in female soldiers: an epidemiological investigation of an outbreak. Mil Med. Sep 1988;153(9):448-50. [Medline].

  7. Maitra RS, Johnson DL. Stress fractures. Clinical history and physical examination. Clin Sports Med. Apr 1997;16(2):259-74. [Medline].

  8. Markey KL. Stress fractures. Clin Sports Med. Apr 1987;6(2):405-25. [Medline].

  9. Devas MB. Stress fractures of the femoral neck. J Bone Joint Surg Br. Nov 1965;47(4):728-38. [Medline]. [Full Text].

  10. Fullerton LR Jr, Snowdy HA. Femoral neck stress fractures. Am J Sports Med. Jul-Aug 1988;16(4):365-77. [Medline].

  11. Monteleone GP Jr. Stress fractures in the athlete. Orthop Clin North Am. Jul 1995;26(3):423-32. [Medline].

  12. Shin AY, Morin WD, Gorman JD, Jones SB, Lapinsky AS. The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J Sports Med. Mar-Apr 1996;24(2):168-76. [Medline].

  13. Holder LE, Schwarz C, Wernicke PG, Michael RH. Radionuclide bone imaging in the early detection of fractures of the proximal femur (hip): multifactorial analysis. Radiology. Feb 1990;174(2):509-15. [Medline]. [Full Text].

  14. Quinn SF, McCarthy JL. Prospective evaluation of patients with suspected hip fracture and indeterminate radiographs: use of T1-weighted MR images. Radiology. May 1993;187(2):469-71. [Medline]. [Full Text].

  15. [Best Evidence] Blomfeldt R, Tornkvist H, Ponzer S, Soderqvist A, Tidermark J. Internal fixation versus hemiarthroplasty for displaced fractures of the femoral neck in elderly patients with severe cognitive impairment. J Bone Joint Surg Br. Apr 2005;87(4):523-9. [Medline].

  16. Stappaerts KH. Early fixation failure in displaced femoral neck fractures. Arch Orthop Trauma Surg. 1985;104(5):314-8. [Medline].

  17. Scheck M. The significance of posterior comminution in femoral neck fractures. Clin Orthop Relat Res. Oct 1980;152:138-42. [Medline].

  18. Heetveld MJ, Raaymakers EL, van Eck-Smit BL, van Walsum AD, Luitse JS. Internal fixation for displaced fractures of the femoral neck. Does bone density affect clinical outcome?. J Bone Joint Surg Br. Mar 2005;87(3):367-73. [Medline].

  19. Arnold WD. The effect of early weight-bearing on the stability of femoral neck fractures treated with Knowles pins. J Bone Joint Surg Am. Jul 1984;66(6):847-52. [Medline]. [Full Text].

  20. Askin SR, Bryan RS. Femoral neck fractures in young adults. Clin Orthop Relat Res. Jan-Feb 1976;114:259-64. [Medline].

  21. Barnes R, Brown JT, Garden RS, Nicoll EA. Subcapital fractures of the femur. A prospective review. J Bone Joint Surg Br. Feb 1976;58(1):2-24. [Medline]. [Full Text].

  22. Bennell KL, Malcolm SA, Thomas SA, et al. Risk factors for stress fractures in track and field athletes. A twelve-month prospective study. Am J Sports Med. Nov-Dec 1996;24(6):810-8. [Medline].

  23. Blickenstaff LD, Morris JM. Fatigue fracture of the femoral neck. J Bone Joint Surg Am. Sep 1966;48(6):1031-47. [Medline]. [Full Text].

  24. [Best Evidence] Blomfeldt R, Tornkvist H, Ponzer S, Soderqvist A, Tidermark J. Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years. J Bone Joint Surg Am. Aug 2005;87(8):1680-8. [Medline].

  25. Bray TJ, Smith-Hoefer E, Hooper A, Timmerman L. The displaced femoral neck fracture. Internal fixation versus bipolar endoprosthesis. Results of a prospective, randomized comparison. Clin Orthop Relat Res. May 1988;230:127-40. [Medline].

  26. Delamarter R, Moreland JR. Treatment of acute femoral neck fractures with total hip arthroplasty. Clin Orthop Relat Res. May 1987;218:68-74. [Medline].

  27. Egol KA, Dolan R, Koval KJ. Functional outcome of surgery for fractures of the ankle. A prospective, randomised comparison of management in a cast or a functional brace. J Bone Joint Surg Br. Mar 2000;82(2):246-9. [Medline]. [Full Text].

  28. Fairclough J, Colhoun E, Johnston D, Williams LA. Bone scanning for suspected hip fractures. A prospective study in elderly patients. J Bone Joint Surg Br. Mar 1987;69(2):251-3. [Medline]. [Full Text].

  29. Figved W, Opland V, Frihagen F, et al. Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures. Clin Orthop Relat Res. Jan 7 2009;epub ahead of print. [Medline].

  30. Garden RS. The significance of good reduction in medial fractures of the femoral neck. Proc R Soc Med. Nov 1970;63(11 pt 1):1122. [Medline]. [Full Text].

  31. Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. Aug 2004;86-A(8):1711-6. [Medline].

  32. Karanicolas PJ, Bhandari M, Walter SD, Heels-Ansdell D, Guyatt GH. Radiographs of hip fractures were digitally altered to mask surgeons to the type of implant without compromising the reliability of quality ratings or making the rating process more difficult. J Clin Epidemiol. Feb 2009;62(2):214-223.e1. [Medline].

  33. Koval KJ, Skovron ML, Aharonoff GB, Zuckerman JD. Predictors of functional recovery after hip fracture in the elderly. Clin Orthop Relat Res. Mar 1998;348:22-8. [Medline].

  34. Magu NK, Rohilla R, Singh R, Tater R. Modified Pauwels' intertrochanteric osteotomy in neglected femoral neck fracture. Clin Orthop Relat Res. Jan 14 2009;epub ahead of print. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

femoral neck fracture, stress fractures of the femoral neck, femur head fracture, hip fracture, leg fracture, broken leg, broken hip, femoral neck stress fracture, hip stress fracture, stress fracture, leg stress fracture, osteoporosis, miserable malalignment syndrome, leg-length discrepancy, female athlete triad, Garden classification, leg length discrepancy, leg length

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Coauthor(s)

Neil N Jasey, Jr, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey
Disclosure: Nothing to disclose.

Jennifer Solomon, MD, Staff Physician, Department On Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey
Jennifer Solomon, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Medical Editor

Janos P Ertl, MD, Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopaedic Surgery, Wishard hospital
Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, and Sierra Sacramento Valley Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Russell D White, MD, Professor of Medicine, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center Lakewood
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.