Neck of femur fracture differential diagnosis

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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

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 + + + - + X-ray
Intertrochanteric Hip Fracture + + + - + X-ray
Subtrochanteric Femur Fracture + + + - + X-ray
Acetabular Fracture + + - + +/- +/- CT
Pubic Rami Fracture + + - + +/- + MRI
Femoral Head Fracture + + + - + Useful in diagnosing occult fractures. CT
Osteoarthritis + + + + +
  • Normal
X-ray
Trochanteric Bursitis + +/- - + + +
  • Normal
  • Normal
MRI
Septic Arthritis + + +/- + + +
  • Normal
  • Normal
MRI
Avascular Necrosis of Head of Femur

(Osteonecrosis)

+ + + + + 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
Femoroacetabular Impingement

(FAI)

+ +
  • External rotation deformity
+ + +
  • Pistol grip deformity: It is asphericity and contour of femoral head and neck indicating Cam impingement.
  • Crossover sign: It is a sign of acetabular retroversion seen in Pincer impingement.
  • Confirms X-ray findings.
  • Evaluates articular cartilage damage, and labral degeneration and tears.
MRI
  • Anterior impingement test: On flexion, adduction, internal rotation of the hip produces pain.
Idiopathic Transient Osteoporosis of the Hip (ITOH) + + - + + +
  • Subchondral cortical loss.
  • Diffuse osteopenia of femoral head and neck.
  • Joint effusion
  • Joint space is always preserved
  • Confirms X-ray findings.
  • Marrow edema of femoral head and neck
MRI
  • Commonly seen among women in 3rd trimester of pregnancy and middle aged men.
  • Bone scan shows increased uptake in the femoral head.
Transient Synovitis of the Hip + +
  • Flexion, abduction and external rotation deformity
+ + +
  • Normal
  • Normal
  • Joint space effusion
USG
  • History of recent upper respiratory tract infection or trauma to the hip.
  • Fever may be present.
  • Involuntary muscle guarding on log rolling of the leg.
  • Ultrasound shows intracapsular effusion and synovial membrane thickening.
Slipped Capital Femoral Epiphysis

(SCFE)

+ +
  • Adduction and external rotation defromity
+ + +
  • Klein's line: A line drawn along superior border femoral neck will intersect less of the femoral head or not at all in a child with SCFE.
  • Epiphysiolysis
  • Blanch sign of Steel: Proximal femoral metaphyseal blurring
  • Confirms X-ray findings.
  • Growth plate widening
  • Edema in metaphysis
MRI
  • Antalgic gait
  • Drehmann sign: External rotation during passive flexion of the hip.
  • Externally rotated foot progression angle.
Adult Dysplasia of the Hip +
  • Increased internal rotation due to increased femoral anteversion
  • External rotation deformity may be present in the late stages.
+ + +
  • Decreased femoral head sphericity.
  • Crossover sign results from increased retroversion.
  • Acetabular protrusio: Decreased lateral center-edge angle < 20°.
  • Increased Tonnis angle ( angle between the horizontal line and line along the superior acetabulum) > 10°.
  • Decreased head-neck offset ratio.
  • Increased femoral neck-shaft angle.
  • Decreased vertical center anterior margin angle.
  • Structural abnormalities of the femoral head and neck is seen.
- X-Ray
  • Positive anterior impingement test may be seen.
Diseases Pain Restriction of Movements Deformity Tenderness Acitve Straight Leg Raising Distal Pulses X-ray CT scan MRI Gold standard Additional findings
Iliospoas Tendinitis + -
  • Flexion and external rotation deformity
+ + +
  • Normal
  • Normal
  • T2 images show an increased signal intensity associated with swelling and inflammation.
MRI
  • Anterior pelvic tilt due to tightening of the iliopsoas muscle.
  • Ludloff sign: Patient asked to sit with knees extended and subsequent elevation of the heel on the affected side causes pain.
  • Ultrasound demonstrates thickened band and fluid in the iliospoas bursa.
Hip Pointer

(Contusion of the Iliac Crest)

+ +/-
  • Adduction and internal rotation deformity may be present.
+ + +
  • Normal
  • Normal
  • Swelling of the surrounding soft tissues may be seen.
-
  • Contusion or swelling may be present.
Snapping Hip Syndrome

(Coxa Saltans)

+/- - - +/- + +
  • Normal
  • Normal
  • May show inflamed bursa.
Ultrasound
  • External snapping hip: Palpate the greater trochanter as hip is actively flexed and applying pressure will likely stop snapping if external band present.
  • Ober's Test: Limited hip adduction when hip held in extension indicate tightness of tensor fascia lata.
  • Internal snapping hip: Snapping is reproduced by passively moving hip from a flexed and externally rotated position to an extended and internally rotated position.
  • Ultrasound shows the snapping band in either internal or external snapping.
Osteitis Pubis + - - + + +
  • Osteolytic pubis with bony erosions
  • Bone marrow edema is seen.
MRI
  • Bone scan shows increased activity in area of pubic symphysis.
Referred Pain from Lumbosacral Plexus + - - + + +
  • Narrowing of the disc space
  • Normal
  • Compression of the nerve root and disc bulge
  • Osteophytes may be seen.
MRI
  • Pain on passive straight leg raising.

References

  1. Rockwood, Charles (2010). Rockwood and Green's fractures in adults. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN 9781605476773.
  2. Azar, Frederick (2017). Campbell's operative orthopaedics. Philadelphia, PA: Elsevier. ISBN 9780323374620.
  3. Hall M, Anderson J (2013). "Hip pointers". Clin Sports Med. 32 (2): 325–30. doi:10.1016/j.csm.2012.12.010. PMID 23522513.
  4. Kelly BT, Maak TG, Larson CM, Bedi A, Zaltz I (2013). "Sports hip injuries: assessment and management". Instr Course Lect. 62: 515–31. PMID 23395055.
  5. Poultsides LA, Bedi A, Kelly BT (2012). "An algorithmic approach to mechanical hip pain". HSS J. 8 (3): 213–24. doi:10.1007/s11420-012-9304-x. PMC 3470663. PMID 24082863.
  6. Battaglia PJ, D'Angelo K, Kettner NW (2016). "Posterior, Lateral, and Anterior Hip Pain Due to Musculoskeletal Origin: A Narrative Literature Review of History, Physical Examination, and Diagnostic Imaging". J Chiropr Med. 15 (4): 281–293. doi:10.1016/j.jcm.2016.08.004. PMC 5106442. PMID 27857636.
  7. Tibor LM, Sekiya JK (2008). "Differential diagnosis of pain around the hip joint". Arthroscopy. 24 (12): 1407–21. doi:10.1016/j.arthro.2008.06.019. PMID 19038713.

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