Fractures and D i s l o c a t i o n s of the Hip and Femur
By Martha A. Norris and Arthur A. De Smet
H E T O P I C O F trauma involving the hip trochanters. The greater trochanter projects
T and femur includes five main categories: superolaterally at the neck-shaft junction and (1) dislocation of the hip; (2) fracture of the serves as the attachment of the gluteus muscles. femoral neck; (3) intertr0chanteric and subtro- The lesser trochanter, inferior and medial to chanteric fractures; (4) fractures of the femoral the greater trochanter, is the insertion site for shaft; and (5) supracondylar fractures. In this the iliopsoas tendon. The trochanters are con- article, each of these topics will be discussed in nected posteriorly by the thick intertrochanteric individual sections. crest. The anteriorly located intertrochanteric W h e n evaluating a patien t with trauma to the line is the site of attachment of the hip cap- hip and femur, the radiographic examination sule. a,2 An important structural component of should always include an anteroposterior (AP) the femoral neck and intertrochanteric region is view of the pelvis, a cross-table lateral view of the calcar femorale, an area of condensed the involved hip, and an AP and lateral view of trabeculae that extends from the posterior as- the femur, which includes the knee, If there is a pect of the femoral neck, through the posterome- question of a minimally impacted but stable dial intertrochanteric area, to the posterome- subcapital fracture on the initial two films, a dial cortex of the subtrochanteric region of the frog,leg lateral view of the hip may be useful. To femoral shaft. 3 image the entire femur, two films of each view are frequently necessary. The femurs should be HIP DISLOCATIONS slightly internally rotated on the AP pelvis film Dislocations of the hip are usually the result in order to best demonstrate the femoral neck. Without internal rotation, the neck will appear of motor vehicle accidents or other severe foreshortened, and fractures are often obscured trauma. 1 The dislocation can occur in the poste- (Figs 1A and 1B). 1 rior, anterior, or central direction. Posterior hip dislocations are the most common type, account- NORMAL ANATOMY OF THE HIP AND ing for 85% to 90% of cases. The usual mecha- PROXIMAL FEMUR nism of injury for posterior dislocations is the flexed knee striking the dashboard during a The femur is the longest bone in the body. motor vehicle accident. 1,4,5Because of the sever- The articular surface of the femoral head is ity of trauma associated with these dislocations smooth except for the medial depression formed by the fovea capitis, the site of attachment of and the mechanism of injury, associated frac- the ligamentum teres. The femoral neck ex- tures of the femoral shaft, tibia, patella, or posterior lip of the acetabulum are common. L4.5 tends from the head to the trochanters and forms a 115 ~ to 140~ angle with the femoral An AP view of the pelvis will readily show a posterior dislocation with the femoral head shaft. The neck also angles anteriorly 125 ~ to lying superior to and overlapping the acetabu- 130 ~ so that the femoral head lies anterior to the lum. On physical examination, the leg is short- ened. Radiographically, the femur is fixed in internal rotation and adduction (Fig 2). 1,6 Typi- ABBREVIATIONS cally, the lesser trochanter is not seen projecting AP, anteroposterior; CT, computed tomography medially from the femur. Femoral head fractures occur in up to 16% of posterior hip dislocations. 7-9 These can be avul- From the Department of Radiology, Universityof Wisconsin sion fractures at the attachment of the ligamen- Hospital and Clinics, Madiso~ WI. turn teres or impaction fractures from the femo- Address reprint reqtceststo Martha A. Norris, MD, Depart- ral head striking the acetabulum. Impaction ment of Radiology, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Madison, W153792. fractures are analogous to the Hill-Sachs frac- Copyright 9 1994 by W.B. Saunders Company ture of the humeral head resulting from an 003 7-198X/ 94/ 2902-000555~ O0/0 anterior shoulder dislocation. 7,s,1~ The impac-
100 Seminars in Roentgenology, Vol XXIX, No 2 (April), 1994: pp 100-112