Neck of femur fracture differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rohan A. Bhimani, M.B.B.S., D.N.B., M.Ch.[2]

Overview

Neck of femur fracture must be differentiated from other causes of acute hip pain, restriction of movements, and deformity such as intertorchanteric hip fracture, osteoarthritis, avascular necrosis, septic arthritis, trochanteric bursitis, slipped capital femoral epiphysis and acute synovitis.

Differentiating Neck of Femur Fracture from other Diseases

• Neck of femur fracture must be differentiated from other causes of acute hip pain, restriction of movements, and deformity such as intertorchanteric hip fracture, osteoarthritis, avascular necrosis, septic arthritis, trochanteric bursitis, slipped capital femoral epiphysis and acute synovitis.

Diseases	Clinical manifestations						Para-clinical findings			Gold standard	Additional findings
	Symptoms			Physical examination
							Imaging
	Pain	Restriction of Movements	Deformity	Tenderness	Active Straight Leg Raising	Distal Pulses	X-ray	CT scan	MRI
Neck of Femur Fracture	+	+	Shortening Externally rotated leg	+	-	+	Fracture fragment displacement Fracture fragment angulation	Accurate diagnosis of fracture pattern ans aids in classification. Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.	Useful in diagnosing occult fractures.	X-ray	Bone scan shows increased uptake of radioactivity in region of fracture.
Intertrochanteric Hip Fracture	+	+	Shortening Externally rotated leg	+	-	+	Fracture fragment displacement Fracture fragment angulation	Accurate diagnosis of fracture pattern ans aids in classification. Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.	Useful in diagnosing occult fractures.	X-ray	Trochanteric Thump test is positive.
Subtrochanteric Femur Fracture	+	+	Thigh is deformed	+	-	+	Fracture fragment displacement Fracture fragment angulation	Accurate diagnosis of fracture pattern ans aids in classification. Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.	Useful in diagnosing occult fractures.	X-ray
Acetabular Fracture	+	+	-	+	+/-	+/-	Fracture fragment displacement Fracture fragment angulation	Accurate diagnosis of fracture pattern ans aids in classification. Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.	Useful in diagnosing occult fractures.	CT	It is a medical emergency as there largee amount of blood loss Per urethral blood may be present Sweeling may be prsent in the scrotal or perineal area.
Pubic Rami Fracture	+	+	-	+	+/-	+	Fracture fragment displacement	Accurate diagnosis of fracture pattern ans aids in classification.	Useful in diagnosing occult fractures.	MRI
Femoral Head Fracture	+	+	May be associated with flexion, adduction and internal rotation deformity.	+	-	+	Fracture fragment displacement Fracture fragment angulation	Accurate diagnosis of fracture pattern ans aids in classification. Useful for preoperative surgical planning for patients with complex, multifragmentary fractures.	Useful in diagnosing occult fractures.	CT	It may be associated with dislocation. It may be associated with foot drop due to compression of the sciatic nerve.
Osteoarthritis	+	+	Flexion and external rotation deformity	+	+	+	X- ray shows joint space narrowing, osteophytes, subchondral sclerosis and subchondral cysts.	Normal	MRI shows cartilage defects and bone marrow lesions.	X-ray	Hip locking, instability and catching sensation.
Trochanteric Bursitis	+	+/-	-	+	+	+	Normal	Normal	MRI shows increased signal in bursa due to inflammation on T2 images.	MRI	Lateral hip pain near the greater trochanter and patients points to greater trochanter. Patient may have trendelenburg gait.
Septic Arthritis	+	+	+/-	+	+	+	Normal	Normal	MRI shows joint fullness and capsular dilation. It also demonstrates damage to the articular cartilage.	MRI	Fever and chills may be present. Hip aspiration may reveal frank pus or a turbid fluid. Culture of the infecting organisms in the fluid is confirmatory. Leukocytosis.
Avascular Necrosis of Head of Femur (Osteonecrosis)	+	+	Adduction deformity	+	+	+	Early x-ray findings include lucency of the femoral head and subchondral sclerosis. In advanced stage, subchondral collapse (ie, crescent sign), femoral head flattening and joint space narrowing is seen.	CT shows subchondral collapse.	MRI shows bone marrow edema and rail track sign.	MRI	Patient may have trendelenburg gait. Passive internal and external rotation of the extended leg may elicit pain due to synovitis. Ficart and Arlet as well as Steinberg classification of avascular necrosis is done radiologically.
Diseases	Pain	Restriction of Movements	Deformity	Tenderness	Acitve Straight Leg Raising	Distal Pulses	X-ray	CT scan	MRI	Gold standard	Additional findings
Acute Synovitis	+	+/-	-	+/-	+	+	Normal	Normal	It helps identify the type of tear and classify the tear. It also aids in management plan for meniscal injury.	MRI	McMurray's est positive for meniscal injury
Slipped Capital Femoral Epiphysis	+	+/-	-	+	+	+	Usually Normal It may show associated avulsion fracture	Normal	It helps to identify partial or complete tear It also aids in distinguishing acute versus chronic tears It may show signs of early degeneration and cartilage wear due to ligament injury	MRI	Lachman test and Anterior Drawer test positive in Anterior cruciate ligament tear (ACL) Posterior drawer test and Dial test positive for posterior cruciate ligament (PCL) Valgus stress test is positive for Medial Collateral Ligament (MCL) Varus stress test is positive for Lateral Collateral Ligament (LCL)
Iliospoas Tendinitis	+	+	+	+	-	+	Usually Normal It may show associated avulsion fracture	Normal	It shows degree of tear It also aids in surgical planning	MRI	Defect present superior to superior pole of patella
Hip Pointer	+	+	-	+	+	+	Fracture of tibial tuberosity apophysis is seen	CT confirms x-ray findings	Swelling and effusion of the joint may be seen	X-ray	Adolescents are commonly affected by the disease.
Snapping Hip Syndrome	+	-	-	+	+	-	Normal	Normal	Normal	Doppler ultrasound	Doppler ultrasound and angiography of the lower limb confirms the disease
Osteitis Pubis	+	+	+	+	+	+	Fracture fragment displacement Fracture fragment angulation	CT confirms x-ray findings	Useful in diagnosing occult fractures, ligamentous and soft tissue injuries	X-ray	Foot drop may be present in few patients Electromyography and Nerve conduction studies done to check for any damage to commom peroneal nerve
Referred Pain from Lumbosacral Plexus