Laboratory Studies

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

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 Devas^[14]and Fullerton and Snowdy,^[15]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.^[16]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.^[17]

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.^[18]Shin et al showed that MRI findings are 100% sensitive, specific, and accurate in identifying a femoral neck fracture.^[16]

Treatment & Management

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Media Gallery

Posterior view of the extraosseous blood supply to the femoral head.
Anterior view of the extraosseous blood supply to the femoral head.
Garden fracture classification.
Classification of femoral neck stress fractures.

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Author

Gerard A Malanga, MD † Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

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, American Institute of Ultrasound in Medicine, International Spine Intervention Society, North American Spine Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Lipogems.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Russell D White, MD Clinical Professor of Medicine, Clinical Professor of Orthopedic Surgery, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood

Russell D White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Family Physicians, American Association of Clinical Endocrinologists, American College of Sports Medicine, American Diabetes Association, American Medical Society for Sports Medicine

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 Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

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, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

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 of 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.