Hip fracture on X‑ray

Written by the X-Ray Atlas editorial team from the sources listed below · Medical review pending · Updated 24 October 2026 · Level: Beginner

Hip fracture, usually a fracture of the neck of femur (NOF), is the most serious common injury of older age. It typically follows a simple fall in someone with osteoporotic bone, and it carries significant mortality and loss of independence. The X-ray has two jobs: find the fracture, which can be subtle when it is impacted or undisplaced, and classify it as intracapsular or extracapsular, because that determines the operation. When the film is normal but the patient cannot weight-bear, remember that a normal hip X-ray does not exclude an occult fracture.

1. Views and how to look

The standard examination is an AP pelvis (showing both hips for comparison) plus a lateral of the affected hip. In trauma, or when the patient cannot move the leg, a horizontal-beam (cross-table) lateral is used. Some fractures are visible only on the lateral.

On the AP pelvis, work through:

1. Shenton's line: a smooth curve along the inferior border of the superior pubic ramus continuing along the medial (inferior) border of the femoral neck. A break or step suggests a NOF fracture or dislocation.
2. The femoral neck cortex: trace the medial and lateral cortices from head to trochanters. The medial cortex is where subtle fractures often show a step.
3. Trabecular pattern: the principal compressive trabeculae run from the medial neck up into the head. Interruption or angulation of these lines is a sign.
4. Compare sides: the neck-shaft angle, the shape of the head-neck junction and the profile of the lesser trochanter.
5. The rest of the pelvis: pubic rami, acetabula, sacrum and sacroiliac joints. Many patients with "hip pain" after a fall have a pubic ramus fracture instead.

2. Signs of a fracture

• A cortical break or step, especially of the medial cortex of the neck.
• A sclerotic band across the neck, caused by impaction of trabeculae. Impacted fractures may show no lucent line at all.
• Angulation of the trabeculae at the head-neck junction.
• Shortening of the neck or a change in the neck-shaft angle compared with the other side.
• External rotation of the femur, which makes the lesser trochanter look more prominent on the AP. Clinically the leg is shortened and externally rotated.
• A broken Shenton's line.

3. Intracapsular vs extracapsular

The hip joint capsule attaches around the base of the femoral neck. This makes the most important distinction in hip fracture management:

Type	Sites	Key issue	Typical surgery
Intracapsular	Subcapital, transcervical (and basicervical at the border)	The retinacular vessels supplying the femoral head run along the neck and can be torn, so there is a risk of avascular necrosis (AVN) and non-union, especially when displaced	Undisplaced: often internal fixation. Displaced: usually hemiarthroplasty or total hip replacement.
Extracapsular	Intertrochanteric (between the trochanters), subtrochanteric (just below the lesser trochanter)	Blood supply to the head is preserved; bleeding into the thigh can be considerable	Fixation, e.g. sliding hip screw or intramedullary nail

Surgical choice is set by guidelines (NICE CG124) and local orthopaedic practice; your job on the film is to say clearly which group the fracture falls into, whether it is displaced, and whether there is comminution or extension below the lesser trochanter.

4. The Garden classification

Garden describes intracapsular fractures on the AP film:

Garden	Description
I	Incomplete, or valgus-impacted (the head is tilted into valgus and impacted on the neck)
II	Complete but undisplaced
III	Complete and partially displaced: the trabeculae of the head no longer line up with those of the acetabulum
IV	Complete and fully displaced: the head has fallen back into a neutral position, so its trabeculae realign with the acetabulum even though it is separated from the neck

Interobserver agreement for the four grades is limited, so in practice the classification is simplified to undisplaced (I–II) vs displaced (III–IV), which is the distinction that drives management.

5. The occult fracture

A small proportion of hip fractures are not visible on the initial radiographs. The typical patient is an older person who has fallen and cannot weight-bear, with pain on hip movement, and an AP and lateral that look normal or equivocal.

• NICE CG124 recommends MRI if a hip fracture is suspected despite negative radiographs. If MRI is not available within 24 hours, or is contraindicated, CT should be considered.
• MRI also shows the alternative diagnoses that cause the same picture: pubic ramus and sacral insufficiency fractures, acetabular fractures, and soft-tissue injury.
• CT is less sensitive than MRI for undisplaced fractures in osteoporotic bone.

6. Other hip injuries

• Hip dislocation: most are posterior (about 90%), from dashboard injuries in road traffic collisions. The femoral head lies superior and lateral to the acetabulum on the AP, the femur is internally rotated and the lesser trochanter is less visible. Look for a posterior acetabular wall fracture, and check the sciatic nerve. Anterior dislocation places the head inferomedially, with the leg externally rotated and abducted. A dislocated hip is an emergency because of the risk of AVN.
• Pathological fracture: a fracture through a lytic or sclerotic lesion after minimal trauma. An isolated avulsion of the lesser trochanter in an adult strongly suggests an underlying lesion such as a metastasis. See bone tumours.
• Atypical femoral fracture: associated with long-term bisphosphonate use. A transverse fracture of the subtrochanteric region or femoral shaft starting in the lateral cortex, often with focal lateral cortical thickening ("beaking"). Image the other femur.
• Stress and insufficiency fractures of the femoral neck: the film is often normal early, then shows a sclerotic line. A compression-side (medial) stress fracture is more stable than a tension-side (lateral) one. MRI is the most sensitive test.
• Children: hip pain in children has a different list, including slipped upper femoral epiphysis and Perthes disease. See paediatric hip.

7. Pitfalls and mimics

• An AP alone: some fractures are visible only on the lateral.
• External rotation of a normal hip foreshortens the neck and can mimic or hide a fracture. Comment on positioning.
• Osteophytes and the overlapping acetabular rim can create lines across the head-neck junction in an arthritic hip. See osteoarthritis.
• Bone islands and Paget disease can alter trabecular patterns.
• Satisfaction of search: a hip fracture and a pubic ramus or wrist fracture can co-exist after the same fall.

Red flags: act now

What to focus on, by role

Role	Priorities
Medical student	Shenton's line, intracapsular vs extracapsular, and Garden undisplaced vs displaced.
Nurse	Recognise the shortened, externally rotated leg, and know that a normal film does not end the assessment in someone who cannot walk. Pressure area care and delirium screening start early.
Junior doctor	Classify the fracture, look at the whole pelvis, request MRI for suspected occult fracture, and start the hip fracture pathway.
Radiographer	AP pelvis plus horizontal-beam lateral without moving the injured leg. Flag subtle impaction with preliminary clinical evaluation.
Advanced / FRCR	Subtle impacted fractures, atypical femoral fractures, pathological fractures and stress fractures.

Practise on real lower limb X-rays →

References

1. NICE CG124. Hip fracture: management. nice.org.uk
2. Radiopaedia. Garden classification of hip fractures. radiopaedia.org
3. Radiology Masterclass. Hip X-ray gallery. radiologymasterclass.co.uk
4. Garden RS. Low-angle fixation in fractures of the femoral neck. J Bone Joint Surg Br 1961;43-B:647–63.
5. Shane E, et al. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the ASBMR. J Bone Miner Res 2014;29:1–23.

For education only. Not a substitute for a formal report, senior review or your local policy. Never use this page to make decisions about a real patient.