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# Hip X-ray: femoral neck fracture

- Reading

In an older person who falls and cannot walk, the hip X-ray looks for a broken femoral neck; if it looks normal but pain persists, MRI is next.

Updated Nov 13, 2026

## Key points

- AP pelvis + lateral hip; compare both sides; trace Shenton line.
- Intracapsular (neck) fractures threaten the femoral head blood supply: avascular necrosis and non-union.
- Garden I–II undisplaced, III–IV displaced.
- Normal X-ray but cannot walk: MRI is the next study.
- Impacted fractures look like a dense white band.

## What it is

Hip fracture in older adults usually follows a low-energy fall in osteoporotic bone. The classic patient has groin pain, cannot bear weight, and the leg may be shortened and externally rotated. The X-ray is an AP view of the pelvis plus a lateral of the affected hip. Fractures are first divided into intracapsular (femoral neck) and extracapsular (intertrochanteric and subtrochanteric). This matters because the femoral head gets most of its blood from vessels that run up the neck (mainly the medial circumflex femoral artery): a displaced neck fracture tears them and risks avascular necrosis and non-union, so it is often treated with arthroplasty, whereas extracapsular fractures usually heal with fixation. Femoral neck fractures are graded by Garden (I to IV) or simply as undisplaced or displaced. Some fractures are occult on X-ray; MRI is then the study of choice, with CT when MRI is not possible.

## What to check

- Shenton line: the smooth arc from the inferior femoral neck to the upper edge of the obturator foramen; a break suggests a fracture or dislocation.
- Look for a lucent or a dense (impacted) line across the neck, a step in the cortex, and a change in the angle of the neck trabeculae.
- Compare both sides on the AP pelvis: neck length, neck–shaft angle and the size of the lesser trochanter (more visible with external rotation).
- Intracapsular = femoral neck (subcapital, transcervical, basicervical); extracapsular = intertrochanteric or subtrochanteric.
- Garden I: incomplete or valgus-impacted; II: complete, undisplaced; III: complete, partly displaced; IV: complete, fully displaced.
- A pubic ramus fracture can cause the same clinical picture: always check the whole pelvis.

## Reading it step by step (and why)

- Ask for an AP pelvis and a lateral of the painful hip — the AP alone can miss a fracture seen only on the lateral.
- Check rotation and both hips on the film — you need the normal side to compare.
- Trace Shenton line on each side — a broken arc points to fracture or dislocation.
- Follow the cortex of the femoral neck above and below — a small step or angulation is often the only sign.
- Look for a dense band across the neck — impacted fractures look white, not dark.
- Decide intracapsular or extracapsular — it predicts blood-supply risk and the operation.
- Grade a neck fracture (Garden, or undisplaced vs displaced) — displacement drives the choice of surgery.
- Look at the rest of the pelvis: pubic rami, acetabulum, sacrum — these mimic hip fracture.
- Look at the bone quality and for lytic or sclerotic areas — a pathological fracture changes the plan.

## Common mistakes

- A «normal» X-ray in an older patient who cannot weight-bear: an occult fracture must be excluded before discharge.
- Missing an impacted (valgus) fracture because it shows as a white band rather than a dark line.
- Only imaging the hip and missing pubic rami or acetabular fractures.
- Forgetting the cause of the fall (syncope, arrhythmia, stroke, medicines) while focusing on the fracture.
- Ignoring a lytic lesion at the fracture site: think metastasis.

## Next step

- Fracture confirmed: orthopaedic referral for surgery, ideally within 24–48 hours, with pain control and a medical review.
- Normal X-ray but strong suspicion (cannot bear weight, pain on rotation): MRI of the hip; CT if MRI is not available or contraindicated.
- Signs of a pathological fracture: tell the radiologist and the surgeon; further imaging and biopsy may be needed.
- After surgery or for any hip fracture in an older adult: assess the cause of the fall and bone health (osteoporosis).

## Test yourself

Think of the answer, then tap the question to see it.

## What is Shenton line and what does its disruption suggest?

The smooth arc from the inferior femoral neck to the upper border of the obturator foramen; a break suggests a hip fracture or dislocation.

## Why are displaced femoral neck fractures at risk of avascular necrosis?

The femoral head is supplied mainly by vessels that run up along the neck (medial circumflex femoral artery), which tear when the neck fracture displaces.

## What is the next study for an older patient who cannot bear weight after a fall but has a normal hip X-ray?

MRI of the hip, the most sensitive study for an occult fracture; CT if MRI cannot be done.

## How can an impacted femoral neck fracture look on X-ray?

As a dense white band across the neck rather than a dark line, often with slight valgus angulation of the head.

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## Elsewhere in DurgiPedia

- [Joint examination: inspection, palpation and range of motion](https://durgical.com/en/clinical-exam/joint-examination-inspection-palpation-and-range-of-motion/)
- [Inspection of gait and posture (orthopedic)](https://durgical.com/en/clinical-exam/inspection-of-gait-and-posture/)

## Connections

## Related 5

- [Describing a fracture on X-ray](https://durgical.com/en/radiology/describing-a-fracture-on-x-ray/)
- [Arthritis on X-ray: osteoarthritis vs inflammatory](https://durgical.com/en/radiology/arthritis-on-x-ray-osteoarthritis-vs-inflammatory/)
- [Bone lesions: aggressive or not](https://durgical.com/en/radiology/bone-lesions-aggressive-or-not/)
- [MRI: T1, T2, FLAIR and diffusion](https://durgical.com/en/radiology/mri-t1-t2-flair-and-diffusion/)
- [CT: windows, Hounsfield units and contrast phases](https://durgical.com/en/radiology/ct-windows-hounsfield-units-and-contrast-phases/)

## Related conditions 6

- [Femoral Neck Fracture](https://durgical.com/en/conditions/femoral-neck-fracture/)
- [Intertrochanteric hip fracture](https://durgical.com/en/conditions/intertrochanteric-hip-fracture/)
- [Osteoporosis](https://durgical.com/en/conditions/osteoporosis/)
- [Falls in older adults](https://durgical.com/en/conditions/falls-in-older-adults/)
- [Hip Osteoarthritis](https://durgical.com/en/conditions/hip-osteoarthritis/)
- [Pelvic fracture](https://durgical.com/en/conditions/pelvic-fracture/)

[← All of radiology](https://durgical.com/en/radiology/)

Educational content; it does not replace a radiologist's report and is not a clinical instruction. Each study is ordered on the patient's assessment and your institution's protocols.

Sources: [Hip Fracture Overview](https://www.ncbi.nlm.nih.gov/books/NBK557514/) (StatPearls (NCBI Bookshelf), 2023); [Femoral Neck Fractures](https://www.ncbi.nlm.nih.gov/books/NBK537347/) (StatPearls (NCBI Bookshelf), 2023).

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/radiology/hip-x-ray-femoral-neck-fracture/