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

• 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	Integrity of extensor mechanism	Distal Pulses	X-ray	CT scan	MRI
Neck of Femur 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, ligamentous and soft tissue injuries	CT
Intertrochanteric Hip Fracture	+	+	-	+	+	+	Evidence of fracture on radiographs is usually seen	Evidence of fracture on CT scan is usually seen.	Soft tissue swelling and tear of the anterior cruciate ligament (ACL) accompanying the fracture is seen	MRI	It is pathgnomic of ACL tear
Subtrochanteric Femur Fracture
Acetabular Fracture
Pubic Rami Fracture
Femoral Head Fracture
Osteoarthritis	+	+	+	+	-	+	Fracture fragment displacement Fracture fragment angulation	CT confirms the x-ray finding.	Swelling and tear of the patellar tendon and the retinaculum may be seen Also helps to identify osteochondral fragments	X-ray	Inability to do straight leg raising test.
Trochanteric Bursitis	+	+	+	+	-	+	Tuberosity avulsion and displacement is seen	CT confirms the x-ray finding	Helps to identify accompanying patellar tendon injury	X-ray	Inability to do straight leg raising test.
Septic Arthritis	+	+	+	+	+/-	+	Disclocated patella Subluxated patella Associated fractures	CT confirms x-ray findings	Identifies damage to medial patellofemoral ligament. Identifies damage to retinacular ligament and orientation of the surrounding muscles	MRI	Apprehension Test positive
Avascular Necrosis of Head of Femur (Osteonecrosis)	+	+	+	+	+/-	+/-	Type of knee dislocation Associated fractures	CT confirms the x-ray findings and shows any osteochondral injury	MRI shows damage to internal structures such as muscles, ligaments and neurovascular bundle.	MRI	Angiography of the lower limb is mandatory to check blood flow to the lower limb and decrease the chances of vascular insult
Diseases	Pain	Restriction of Movements	Deformity	Tenderness	Integrity of extensor mechanism	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