Could the HU value of the femoral head be used to distinguish between different types of hip fracture, and to predict the severity of intertrochanteric fractures？

Could the HU value of the femoral head be used to distinguish between different types of hip fracture, and to predict the severity of intertrochanteric fractures？ | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Could the HU value of the femoral head be used to distinguish between different types of hip fracture, and to predict the severity of intertrochanteric fractures？ Wenjie Qin, Jiangyun Liao, Jianwen Cheng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7913552/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background As the global population ages, hip fractures have become a significant public health concern. Although computed tomography (CT)-derived Hounsfield units (HU) offer a new perspective for assessing bone density, their value in predicting hip fracture type and stability remains unclear. This study aims to investigate whether femoral head Hounsfield unit (HU) values can distinguish between femoral neck and intertrochanteric fractures, and whether they can be used to predict the complexity of intertrochanteric fractures. Methods A total of 234 hip fracture patients (117 with femoral neck fractures and 117 with intertrochanteric fractures) were selected based on inclusion and exclusion criteria. The mean HU value of the femoral head was measured on preoperative CT images. Based on the AO/OTA classification, intertrochanteric fractures were categorized as either stable (A1.1-A2.1) or unstable (A2.2-A3). Statistical comparisons were performed using independent-samples t-tests, chi-square tests and analysis of variance. Results No significant difference in overall HU values was observed between the femoral neck fracture group and the intertrochanteric fracture group. However, within the intertrochanteric fracture subgroup, HU values for unstable fractures were significantly lower than for stable fractures. Mean HU values were significantly higher in male patients than in females, with this difference persisting in both stable and unstable fracture groups. The subgroup with the lowest bone density was female patients with unstable fractures. Conclusion Although femoral head HU values cannot distinguish between femoral neck and intertrochanteric fractures, they can be used to predict intertrochanteric fracture stability and identify high-risk patients. Hounsfield units hip fractures bone density fracture fixation osteoporosis Figures Figure 1 Introduction With the accelerating pace of societal ageing, hip fractures have become a prominent feature of orthopaedic clinical practice. They are a common and highly destructive skeletal disorder among the elderly population and have become a major challenge for global public health [ 1 ] . Hip fractures have a catastrophic impact on the quality of life of elderly patients and impose a heavy burden on medical resources at household, societal and national levels. They often lead to prolonged bed rest, triggering severe complications such as pneumonia, thrombosis and pressure ulcers, and significantly increasing disability rates and mortality. Statistics indicate that the mortality rate among hip fracture patients within one year of injury can be as high as 20%-30% [ 2 ] . This grim reality highlights the necessity for in-depth research and effective interventions aimed at hip fractures. Previous studies have clearly established a strong association between hip fracture occurrence and osteoporosis [ 3 ] . Among the key indicators used to assess fracture risk, bone mineral density (BMD) has long been considered the most important. Dual-energy X-ray absorptiometry (DEXA), recognised for its accuracy and reliability, is widely regarded as the gold standard for measuring bone density and is extensively used in clinical practice and research [ 4 – 5 ] . However, DEXA measurements primarily focus on central skeletal sites [ 6 ] , presenting limitations when it comes to assessing peripheral bones such as the hip. This restricts their comprehensiveness and precision when it comes to evaluating hip fracture risk. In recent years, however, imaging technology has advanced dramatically. Continuous improvements in computed tomography (CT) technology have opened up new perspectives and approaches to hip fracture assessment. CT provides high-resolution skeletal images that clearly display fine bone structures and enables precise bone density measurements, offering clinicians richer and more accurate diagnostic information. The most common types of hip fracture in elderly patients are femoral neck fractures (FNF) and intertrochanteric fractures (IFF), which often require surgical intervention. However, patients often struggle to regain their preoperative activity levels after surgery, particularly those with intertrochanteric fractures, which frequently result in deficits in limb function [ 7 ] . This is related to the fracture type and the healing process [ 8 ] . This substantially compromises patients' quality of life and functional independence. Therefore, the ability to predict fracture type and severity based on bone density status would play a crucial role in preventing and treating hip fractures in the elderly. It would facilitate the development of more precise treatment plans, thereby improving patient outcomes and quality of life. As the femoral head is a critical component of the hip joint, changes in its bone quality may be closely associated with the occurrence and progression of hip fractures. This study aims to explore the potential value of Hounsfield unit (HU) values in predicting hip fracture types by comparing differences in femoral head HU values on CT scans between patients with intertrochanteric fractures and those with femoral neck fractures.Furthermore, this study will evaluate whether femoral head HU values can predict the severity of intertrochanteric fractures. The study aims to provide clinicians with a novel, more effective method of assessing hip fractures and robust evidence to support the prevention, diagnosis and treatment of hip fractures in elderly patients. Materials and Methods This retrospective study was approved by the ethics committee at our hospital. Due to the retrospective nature of the analysis, informed consent was waived. We reviewed the medical records of all patients aged 65 years or older who had sustained either a femoral neck or an intertrochanteric fracture between January 2022 and December 2024. We included patients who underwent three-dimensional (3D) bilateral hip CT scans at our institution. The exclusion criteria were: (1) high-energy trauma; (2) CT scans performed at other institutions; and (3) prior surgery or conditions affecting the measurement sites (e.g. avascular necrosis of the femoral head, osteoarthritis or bone cysts). Motor vehicle accidents and falls from a height of more than two metres were defined as high-energy trauma, while falls from standing height were classified as low-energy trauma [ 9 ] . Ultimately, a total of 234 patients were included in the study. Demographic data, including age at injury, gender and body mass index, were collected through reviewing medical records and CT images. There were 117 cases of both femoral neck and intertrochanteric fractures. The mean age at surgery for patients with a femoral neck fracture was 76.70 ± 8.24 years (range 65–92 years). Of these patients, 52 were male and 65 were female. The mean age at surgery for patients with intertrochanteric fractures was 79.56 ± 8.40 years (range 66–94 years). Among these patients, 54 were male and 63 were female. Regarding fracture classification, the AO classification system provides superior guidance for clinical decision-making and surgical planning for intertrochanteric fractures. This classification system was adopted in our study to characterise the intertrochanteric fracture cohort, dividing it into two subgroups: stable fractures (A1.1–A2.1) and unstable fractures (A2.2–A3). All patients underwent CT scanning of the hip using a Somatom Sensation-64 (Siemens, Erlangen, Germany), with parameters set at 120 kVp and a slice thickness of 3.0 mm. Patients were positioned supine during CT acquisition. Hounsfield unit (HU) measurements were obtained using a GE Healthcare Picture Archiving and Communication System (PACS). Assuming no disease or local factors were interfering, bilateral femoral head bone density was considered consistent for the same patient. Therefore, the average HU value was obtained by measuring the unaffected femoral head. Parameter measurement and reliability testing: An expert panel comprising two orthopaedic surgeons and one radiologist with over five years' experience was convened. A consensus-building meeting was held prior to CT image measurements. The panel determined HU values by placing circular regions of interest (ROIs) at the centre of the largest cross-sectional area of the femoral head in each phase. Specifically, the largest possible circular or elliptical area was delineated on the largest slice of the contralateral femoral head CT in the transverse, sagittal and coronal planes, avoiding the cortical margin. The HU values obtained from these three slices were averaged to generate the mean HU value of the femoral head. This method aligns with previous studies [ 10 – 12 ] . The stability of intertrochanteric fractures after reduction was categorised into two subgroups: stable fractures (A1.1–A2.1) and unstable fractures (A2.2–A3). Figure 1 illustrates this technique. Statistical Analysis Statistical analysis was performed using IBM SPSS Statistics Version 22.0. Continuous variables are presented as the mean ± standard deviation (SD), while categorical variables are expressed as frequencies and percentages. Comparisons of continuous variables between groups were conducted using an independent samples t-test, while comparisons of categorical variables were performed using a Pearson's chi-square test. For comparisons involving more than two groups, analysis of variance (ANOVA) was performed based on homogeneity of variance (assessed using Levene's test). The linear relationship between age and Hounsfield unit (HU) values was evaluated using Pearson's correlation coefficient. The diagnostic efficacy of HU values in distinguishing fracture status was evaluated using receiver operating characteristic (ROC) curve analysis, with statistical significance defined as a p-value < 0.05. Results In this retrospective study, 234 patients met the inclusion criteria and did not fulfil the exclusion criteria. Of these patients, 117 had a diagnosis of intertrochanteric femoral fracture and 117 had a diagnosis of femoral neck fracture. The general data, such as age, body mass index, gender, diabetes mellitus, smoking and use of anti-osteoporosis medication, were compared between the intertrochanteric femoral fracture group and the femoral neck fracture group. The differences were not statistically significant (P > 0.05). See Table 1 . Table 1 Patient demographics Variable IFF FPF Value 117 117 Age (yrs) 79.56 ± 8.40 76.70 ± 8.24 0.009 BMI (kg/m2) 26.5 ± 5.4 24.7 ± 4.5 2.77 Gender Male 54 52 0.793 Female 63 65 Diabetes mellitus 32(27.4%) 35(29.9%) 0.664 Tobacco use 21(17.9%) 25(21.4%) 0.510 Use of anti- osteoporosis drugs 22 (18.8%) 18(15.4%) 0.487 A comparison of the Hounsfield Unit (HU) values of the two fractures showed that, in the intertrochanteric femoral fracture group, the mean bone mineral density (BMD) was 173.99 ± 48.86 HU (range 96–261). In the femoral neck fracture group, the mean BMD was 177.75 ± 38.35 HU (range 68–264). There was no significant difference between the two groups (P > 0.05), as shown in Table 2 . Among patients with intertrochanteric femoral fractures, according to AO typing, there were 60 stable fractures (46 type A1 and 14 type A2.1), with a mean BMD of 196.25 ± 44.08 HU, and 57 unstable fractures (50 type A2 and seven type A3). The HU values were significantly lower (P < 0.05) in the unstable fracture group than in the stable fracture group (see Table 3 ). Of the 117 patients with intertrochanteric fractures in this study, 54 (46.2%) were male and 63 (53.8%) were female. Stratification according to fracture stability showed that 21 (38.9%) of the male patients had stable fractures, while 33 (61.1%) had unstable fractures. In contrast, 17 (27.0%) of the female patients had stable fractures, while 46 (73.0%) had unstable fractures. There were differences in bone density between the genders: the bone density (HU value) of the 54 male patients was (197.38 ± 53.38) HU, which was significantly higher than that of the 63 female patients (157.99 ± 38.27 HU) (p < 0.01). The large effect size (Cohen's d = 0.86) indicates that the mean bone mineral density (BMD) of male patients was 39.39 HUs higher than that of females (95% confidence interval: 23.15–55.63). A comparison of fracture types within the same sex revealed significantly lower HU values in the unstable fracture group than in the stable fracture group for both male and female patients (p < 0.05). Among patients with stable fractures, comparison between genders showed significantly higher HU values in males (220.67 ± 43.39 HU) than in females (171.82 ± 38.53 HU) (p < 0.01). In patients with unstable fractures, the mean male HU value (182.83 ± 56.38) was significantly higher than the mean female HU value (146.19 ± 46.93) (p < 0.01). See Table 4 . Table 2 Comparison of HU values between intertrochanteric fractures and femoral neck fractures Variable IFF FPF Value Mean HU value 173.99 ± 48.86 177.75 ± 38.35 0.513 Table 3 Classification comparison of intertrochanteric fractures of the femur Fracture Type Stable Fracture(A1.1-A2.1) Unstable Fracture(A2.2-A3) Number of Cases 60 57 Mean HU value 196.25 ± 44.08 169.44 ± 47.87 Statistical Value t = 3.11 P-Value P<0.05 Table 4 HU Values by Gender and Fracture Stability in Intertrochanteric Fractures. Group Fracture Type Statistical Value p-value Stable Fracture Unstable Fracture Male (n = 54) Patients(n) 21 33 HU value 220.67 ± 43.39 182.83 ± 56.38 2.618 P<0.05 Total HU value 197.38 ± 53.38 Female (n = 63) Patients(n) 17 46 HU value 171.82 ± 38.53 146.19 ± 46.93 2.204 P<0.05 Total HU value 157.99 ± 38.27 Statistical Value 3.971 3.476 p-value <0.01 <0.01 Discussion As the population ages, the incidence of osteoporosis-related fractures among the elderly is increasing year on year. On average, an osteoporotic fracture occurs every three seconds, and osteoporosis results in more than 8.9 million fractures annually [ 13 ] . Prevention, risk assessment and optimisation of treatment strategies for the two most predominant hip fracture types, femoral neck fracture (FNF) and intertrochanteric femoral fracture (IFF), have been a central theme in orthopaedics. Previous studies have shown that HU values derived from CT scans accurately reflect local bone density and are unaffected by human factors [ 10 ] . Through the present study, we found no significant difference in mean HU values of the femoral head between fractures of the neck of the femur and intertrochanteric fractures. Nevertheless, this finding does not contradict the biomechanical law that severe osteoporosis is the common pathological basis of all hip fragility fractures [ 14 ] . The specific type of fracture is more likely to be determined by the direction of the force applied during the fall, the severity of the local bone microstructure and anatomical specificity than by the overall bone mineral density of the femoral head alone. This also suggests that, although the HU value of the femoral head is a useful and convenient indicator for assessing the overall bone quality of the hip, it is not sensitive enough to predict the type of proximal femoral fracture. However, it is a strong predictor when assessing the stability of intertrochanteric femoral fractures. Patients with unstable fractures (AO/OTA 31-A2.2 to A3) had significantly lower Hounsfield Unit (HU) values than those with stable fractures (AO/OTA A1.1 to A2.1). This association is intuitive from a mechanical perspective: patients with reduced BMD have reduced trabecular strength and connectivity. Under traumatic loading, this leads to more severe comminution and posterior medial cortical breaks, ultimately resulting in an unstable fracture pattern. This is similar to studies by others [ 15 ] . This finding provides surgeons with a quantifiable preoperative imaging marker to alert them to a higher likelihood of encountering a complex fracture. This aids preoperative planning and endoprosthesis selection (e.g. standard versus elongated cephalomedullary nails) and improves communication with patients. Furthermore, it may help clinicians anticipate postoperative fracture complications, such as internal fixation failure and screw cut-out. This study revealed a significant interaction between gender and fracture stability. It revealed gender dimorphism, consistent with previous studies [ 16 ] . While HU values were generally higher in males than in females, the decrease in BMD from stable to unstable fractures was more pronounced in males (ΔHU = 37.84) than in females (ΔHU = 25.63). Notably, the unstable fracture group had the lowest mean absolute HU value in female patients (146.19 ± 46.93), which is typically below the threshold commonly used for diagnosing osteoporosis on CT scans. This suggests that, due to accelerated deterioration of bone microarchitecture after menopause and possible concomitant muscle mass loss [ 17 – 19 ] , women may be susceptible to unstable fractures at relatively high BMD. The most impactful finding of our study was that, despite the clear association between low Hounsfield unit (HU) values, female gender and unstable fracture types, we found no evidence that these factors resulted in worse clinical outcomes in patients undergoing surgical treatment. This finding seems to contradict the extensive historical literature linking osteoporosis to poor fracture fixation outcomes [ 20 – 21 ] . While many previous studies have found that patients with poor bone quality have a worse prognosis [ 22 ] , we believe that this negative impact can be effectively overcome with improved techniques and the appropriate use of endografts. This study also has some limitations. The retrospective design may be susceptible to selection bias. In this study, we measured the HU value of the femoral head as an indicator of bone mineral density. This could not be measured accurately or directly in the area of the femoral neck or trochanteric fracture due to the fracture itself. This may have influenced the results. Furthermore, we lacked direct assessment of bone microarchitecture (e.g. trabecular bone score), which could provide additional prognostic information beyond density. In conclusion, our study suggests that femoral head HU values cannot be used to differentiate between femoral neck and intertrochanteric fractures. Declarations Ethics approval and consent to participate All of the following procedures followed the ethical standards of the National Committees on Human Experimentation and the Helsinki Declaration of 1964 and later versions and were approved by the Medical Ethics Committee of Liuzhou Worker's Hospital. Informed consent was waived because of the retrospective nature of this study according to the Medical Ethics Committee of Liuzhou Worker's Hospital. Consent for publication Consent was obtained from all participants for publication of this result and the accompanying images. Availability of data and materials The datasets used or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding No funds have been received to support the work. Authors' contributions Wenjie Qin: study design, data collection, and interpretation, figures, and article writing. Jiangyun Liao: statistical analysis, data collection. Jianwen Cheng: study design, article editing, and checking the final version. The author(s) read and approved the final manuscript. Acknowledgments We would like to express gratitude to all the patients and their families. We also acknowledge the information Department of our hospital for providing support. References McDonough CM, Harris-Hayes M, Kristensen MT, Overgaard JA, Herring TB, Kenny AM, et al. Physical therapy management of older adults with hip fracture. J Orthop Sports Phys Ther. 2021;51(2):CPG1–81. Downey C, Kelly M, Quinlan JF. Changing trends in the mortality rate at 1-year post hip fracture - a systematic review. World J Orthop., Johnell O, Kanis JA. (2006). An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporosis International, 17, 1726–1733. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006;17(12):1726–33. AbuAlrob H, Ioannidis G, Jaglal S, Costa A, Griffith LE, Thabane L, et al. Hip fracture rate and osteoporosis treatment in Ontario: A population-based retrospective cohort study. Arch Osteoporos. 2024;19(1):53. Chen M, Gerges M, Raynor WY, Park PSU, Nguyen E, Chan DH, et al. State of the Art Imaging of Osteoporosis. Semin Nucl Med. 2024;54(3):415–26. Lee SY, Kwon SS, Kim TH, Shin SJ. Is central skeleton bone quality a predictor of the severity of proximal humeral fractures? Injury. 2016;47(12):2777–82. Prakash A, Nagakumar JS, Arun SH, Sagar V, Amith K. A Comparative Study of Functional Outcome Following Dynamic Hip Screw and Proximal Femoral Nailing for Intertrochanteric Fractures of the Femur. Cureus. 2022;14(4):e23803. Lee KM, Chung CY, Kwon SS, Won SH, Lee SY, Chung MK, et al. Ankle fractures have features of an osteoporotic fracture. Osteoporos Int. 2013;24(11):2819–25. 10.1007/s00198-013-2366-x . Schreiber JJ, Anderson PA, Rosas HG, Buchholz AL, Au AG. Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Joint Surg Am. 2011;93(11):1057–63. Pickhardt PJ, Pooler BD, Lauder T, del Rio AM, Bruce RJ, Binkley N. Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med. 2013;158(8):588–95. Schreiber JJ, Gausden EB, Anderson PA, Carlson MG, Weiland AJ. Opportunistic Osteoporosis Screening - Gleaning Additional Information from Diagnostic Wrist CT Scans. J Bone Joint Surg Am. 2015;97(13):1095–100. Wright NC, Looker AC, Saag KG, Curtis JR, Delzell ES, Randall S, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Min Res. 2014;29(11):2520–6. Chin KY, Soelaiman IN, Naina Mohamed I, Mohamed N, Muhammad N, Wan Ngah WZ. Bone mineral density and trabecular bone score in elderly type 2 diabetes Southeast Asian patients with severe osteoporotic hip fractures. PLoS ONE. 2020;15(11):e0241616. Gautam KP, Cherian KE, Kapoor N, Thomas N, Paul TV. Utility and validation of bone mineral density measurements at forearm in predicting trabecular microarchitecture and central-site osteoporosis in aging Indian postmenopausal women—a promising surrogate? Aging Med (Milton). 2022;5(1):30–7. Zhang YY, Xie N, Sun XD, Nice EC, Liou YC, Huang C, et al. Insights and implications of sexual dimorphism in osteoporosis. Bone Res. 2024;12(1):20. 10.1038/s41413-024-00318-8 . Sohi YH, Golestani A, Panahi G, TabatabaeiMalazy O, Khalagi K, Fahimfar N, et al. The association between anti-diabetic agents and osteoporosis, sarcopenia, and osteosarcopenia among Iranian older adults; Bushehr Elderly Health (BEH) program. Daru. 2023;32(1):145–59. Sherly Shulamite N, Pragna Malavika B, Aravinda Swami P. Overview of the Pharmacological Management of Osteoporosis in Postmenopausal Women. J Pharm Res Int. 2021;33(58A):220–9. Farshbaf-Khalili A, Malekian S, Efteharsadat B, Ghahremaninasab P, Pourzeinali S. The associations between bone mineral density with body composition parameters in postmenopausal women. Adv Gerontol. Wang P, Li Y, Zhuang H, Yu H, Cai S, Xu H, et al. Influence of bone densitometry on the anti-osteoporosis treatment after fragility hip fracture. Aging Clin Exp Res. 2019;31(10):1525–9. Schreiber JJ, Anderson PA, Hsu WK. Use of computed tomography for assessing bone mineral density. Neurosurg Focus. 2014;37(1):E4. Jiang S, Ding Y, Kang L. Impact of sarcopenia on intertrochanteric femoral fracture in the elderly. PeerJ. 2022;10:e13445. Chen O, Hu Y, Xu B, Xu W. Impact of combining alfacalcidol with proximal femoral nail antirotation on bone mineral density, serum bone metabolites, and inflammatory markers in elderly patients with osteoporotic intertrochanteric fractures. Ann Ital Chir. 2025;96(9):1180–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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10:15:56","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":43698,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinegroupimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7913552/v1/96a5dea1ff688d2ae72e345c.png"},{"id":95529290,"identity":"33c0a599-4b73-4fe3-b64a-bc4cfb9223e6","added_by":"auto","created_at":"2025-11-10 10:16:57","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":43698,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinegroupimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7913552/v1/472bd94324f6359bc702feb2.png"},{"id":95528241,"identity":"c939f29f-c622-4f13-ae59-19ed9b10bc24","added_by":"auto","created_at":"2025-11-10 10:15:44","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78853,"visible":true,"origin":"","legend":"","description":"","filename":"882f6e6824e64b46a02dfc98bae21cfb1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7913552/v1/424e9072543685eab5ee0ef0.xml"},{"id":95503667,"identity":"bf71debe-54c8-4040-9fe5-5b4adb619b5f","added_by":"auto","created_at":"2025-11-10 05:40:47","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":85113,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7913552/v1/4066447d483f631d913e140d.html"},{"id":95503663,"identity":"7c2bb1fe-6b6f-4a36-890a-0e7191bc8d09","added_by":"auto","created_at":"2025-11-10 05:40:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1245158,"visible":true,"origin":"","legend":"\u003cp\u003eillustrates the process of calculating the mean Hounsfield unit (HU) value of the contralateral femoral head. Examples of regions of interest (ROIs) for Hounsfield units are shown on three-phase computed tomography (CT) images of the femoral head.A=148.29 HU,B=199.90 HU,C=193.58HU.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7913552/v1/037484aaa51c112855cd9300.png"},{"id":97665211,"identity":"308bb24e-45ac-4903-b746-04ae6ad38f07","added_by":"auto","created_at":"2025-12-08 09:17:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1928831,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7913552/v1/457afb74-db25-433c-aa06-7b9f30e131f1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Could the HU value of the femoral head be used to distinguish between different types of hip fracture, and to predict the severity of intertrochanteric fractures？","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith the accelerating pace of societal ageing, hip fractures have become a prominent feature of orthopaedic clinical practice. They are a common and highly destructive skeletal disorder among the elderly population and have become a major challenge for global public health\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Hip fractures have a catastrophic impact on the quality of life of elderly patients and impose a heavy burden on medical resources at household, societal and national levels. They often lead to prolonged bed rest, triggering severe complications such as pneumonia, thrombosis and pressure ulcers, and significantly increasing disability rates and mortality. Statistics indicate that the mortality rate among hip fracture patients within one year of injury can be as high as 20%-30% \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. This grim reality highlights the necessity for in-depth research and effective interventions aimed at hip fractures. Previous studies have clearly established a strong association between hip fracture occurrence and osteoporosis \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Among the key indicators used to assess fracture risk, bone mineral density (BMD) has long been considered the most important. Dual-energy X-ray absorptiometry (DEXA), recognised for its accuracy and reliability, is widely regarded as the gold standard for measuring bone density and is extensively used in clinical practice and research \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. However, DEXA measurements primarily focus on central skeletal sites\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e, presenting limitations when it comes to assessing peripheral bones such as the hip. This restricts their comprehensiveness and precision when it comes to evaluating hip fracture risk. In recent years, however, imaging technology has advanced dramatically. Continuous improvements in computed tomography (CT) technology have opened up new perspectives and approaches to hip fracture assessment. CT provides high-resolution skeletal images that clearly display fine bone structures and enables precise bone density measurements, offering clinicians richer and more accurate diagnostic information. The most common types of hip fracture in elderly patients are femoral neck fractures (FNF) and intertrochanteric fractures (IFF), which often require surgical intervention. However, patients often struggle to regain their preoperative activity levels after surgery, particularly those with intertrochanteric fractures, which frequently result in deficits in limb function\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. This is related to the fracture type and the healing process\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. This substantially compromises patients' quality of life and functional independence. Therefore, the ability to predict fracture type and severity based on bone density status would play a crucial role in preventing and treating hip fractures in the elderly. It would facilitate the development of more precise treatment plans, thereby improving patient outcomes and quality of life. As the femoral head is a critical component of the hip joint, changes in its bone quality may be closely associated with the occurrence and progression of hip fractures. This study aims to explore the potential value of Hounsfield unit (HU) values in predicting hip fracture types by comparing differences in femoral head HU values on CT scans between patients with intertrochanteric fractures and those with femoral neck fractures.Furthermore, this study will evaluate whether femoral head HU values can predict the severity of intertrochanteric fractures. The study aims to provide clinicians with a novel, more effective method of assessing hip fractures and robust evidence to support the prevention, diagnosis and treatment of hip fractures in elderly patients.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e This retrospective study was approved by the ethics committee at our hospital. Due to the retrospective nature of the analysis, informed consent was waived. We reviewed the medical records of all patients aged 65 years or older who had sustained either a femoral neck or an intertrochanteric fracture between January 2022 and December 2024. We included patients who underwent three-dimensional (3D) bilateral hip CT scans at our institution. The exclusion criteria were: (1) high-energy trauma; (2) CT scans performed at other institutions; and (3) prior surgery or conditions affecting the measurement sites (e.g. avascular necrosis of the femoral head, osteoarthritis or bone cysts). Motor vehicle accidents and falls from a height of more than two metres were defined as high-energy trauma, while falls from standing height were classified as low-energy trauma\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Ultimately, a total of 234 patients were included in the study. Demographic data, including age at injury, gender and body mass index, were collected through reviewing medical records and CT images. There were 117 cases of both femoral neck and intertrochanteric fractures. The mean age at surgery for patients with a femoral neck fracture was 76.70\u0026thinsp;\u0026plusmn;\u0026thinsp;8.24 years (range 65\u0026ndash;92 years). Of these patients, 52 were male and 65 were female. The mean age at surgery for patients with intertrochanteric fractures was 79.56\u0026thinsp;\u0026plusmn;\u0026thinsp;8.40 years (range 66\u0026ndash;94 years). Among these patients, 54 were male and 63 were female. Regarding fracture classification, the AO classification system provides superior guidance for clinical decision-making and surgical planning for intertrochanteric fractures. This classification system was adopted in our study to characterise the intertrochanteric fracture cohort, dividing it into two subgroups: stable fractures (A1.1\u0026ndash;A2.1) and unstable fractures (A2.2\u0026ndash;A3).\u003c/p\u003e\u003cp\u003eAll patients underwent CT scanning of the hip using a Somatom Sensation-64 (Siemens, Erlangen, Germany), with parameters set at 120 kVp and a slice thickness of 3.0 mm. Patients were positioned supine during CT acquisition. Hounsfield unit (HU) measurements were obtained using a GE Healthcare Picture Archiving and Communication System (PACS). Assuming no disease or local factors were interfering, bilateral femoral head bone density was considered consistent for the same patient. Therefore, the average HU value was obtained by measuring the unaffected femoral head.\u003c/p\u003e\u003cp\u003eParameter measurement and reliability testing: An expert panel comprising two orthopaedic surgeons and one radiologist with over five years' experience was convened. A consensus-building meeting was held prior to CT image measurements. The panel determined HU values by placing circular regions of interest (ROIs) at the centre of the largest cross-sectional area of the femoral head in each phase. Specifically, the largest possible circular or elliptical area was delineated on the largest slice of the contralateral femoral head CT in the transverse, sagittal and coronal planes, avoiding the cortical margin. The HU values obtained from these three slices were averaged to generate the mean HU value of the femoral head. This method aligns with previous studies\u003csup\u003e[\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. The stability of intertrochanteric fractures after reduction was categorised into two subgroups: stable fractures (A1.1\u0026ndash;A2.1) and unstable fractures (A2.2\u0026ndash;A3). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates this technique.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was performed using IBM SPSS Statistics Version 22.0. Continuous variables are presented as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), while categorical variables are expressed as frequencies and percentages. Comparisons of continuous variables between groups were conducted using an independent samples t-test, while comparisons of categorical variables were performed using a Pearson's chi-square test. For comparisons involving more than two groups, analysis of variance (ANOVA) was performed based on homogeneity of variance (assessed using Levene's test). The linear relationship between age and Hounsfield unit (HU) values was evaluated using Pearson's correlation coefficient. The diagnostic efficacy of HU values in distinguishing fracture status was evaluated using receiver operating characteristic (ROC) curve analysis, with statistical significance defined as a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn this retrospective study, 234 patients met the inclusion criteria and did not fulfil the exclusion criteria. Of these patients, 117 had a diagnosis of intertrochanteric femoral fracture and 117 had a diagnosis of femoral neck fracture. The general data, such as age, body mass index, gender, diabetes mellitus, smoking and use of anti-osteoporosis medication, were compared between the intertrochanteric femoral fracture group and the femoral neck fracture group. The differences were not statistically significant (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient demographics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIFF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFPF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eValue\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e117\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (yrs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79.56\u0026thinsp;\u0026plusmn;\u0026thinsp;8.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76.70\u0026thinsp;\u0026plusmn;\u0026thinsp;8.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.009\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI (kg/m2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.77\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.793\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes mellitus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32(27.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35(29.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.664\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTobacco use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21(17.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25(21.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.510\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of anti- osteoporosis drugs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (18.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18(15.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.487\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA comparison of the Hounsfield Unit (HU) values of the two fractures showed that, in the intertrochanteric femoral fracture group, the mean bone mineral density (BMD) was 173.99\u0026thinsp;\u0026plusmn;\u0026thinsp;48.86 HU (range 96\u0026ndash;261). In the femoral neck fracture group, the mean BMD was 177.75\u0026thinsp;\u0026plusmn;\u0026thinsp;38.35 HU (range 68\u0026ndash;264). There was no significant difference between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eAmong patients with intertrochanteric femoral fractures, according to AO typing, there were 60 stable fractures (46 type A1 and 14 type A2.1), with a mean BMD of 196.25\u0026thinsp;\u0026plusmn;\u0026thinsp;44.08 HU, and 57 unstable fractures (50 type A2 and seven type A3). The HU values were significantly lower (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in the unstable fracture group than in the stable fracture group (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOf the 117 patients with intertrochanteric fractures in this study, 54 (46.2%) were male and 63 (53.8%) were female. Stratification according to fracture stability showed that 21 (38.9%) of the male patients had stable fractures, while 33 (61.1%) had unstable fractures. In contrast, 17 (27.0%) of the female patients had stable fractures, while 46 (73.0%) had unstable fractures. There were differences in bone density between the genders: the bone density (HU value) of the 54 male patients was (197.38\u0026thinsp;\u0026plusmn;\u0026thinsp;53.38) HU, which was significantly higher than that of the 63 female patients (157.99\u0026thinsp;\u0026plusmn;\u0026thinsp;38.27 HU) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The large effect size (Cohen's d\u0026thinsp;=\u0026thinsp;0.86) indicates that the mean bone mineral density (BMD) of male patients was 39.39 HUs higher than that of females (95% confidence interval: 23.15\u0026ndash;55.63). A comparison of fracture types within the same sex revealed significantly lower HU values in the unstable fracture group than in the stable fracture group for both male and female patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Among patients with stable fractures, comparison between genders showed significantly higher HU values in males (220.67\u0026thinsp;\u0026plusmn;\u0026thinsp;43.39 HU) than in females (171.82\u0026thinsp;\u0026plusmn;\u0026thinsp;38.53 HU) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). In patients with unstable fractures, the mean male HU value (182.83\u0026thinsp;\u0026plusmn;\u0026thinsp;56.38) was significantly higher than the mean female HU value (146.19\u0026thinsp;\u0026plusmn;\u0026thinsp;46.93) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). See Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of HU values between intertrochanteric fractures and femoral neck fractures\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIFF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFPF\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eValue\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean HU value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e173.99\u0026thinsp;\u0026plusmn;\u0026thinsp;48.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e177.75\u0026thinsp;\u0026plusmn;\u0026thinsp;38.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.513\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClassification comparison of intertrochanteric fractures of the femur\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eFracture Type\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStable Fracture(A1.1-A2.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnstable Fracture(A2.2-A3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of Cases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean HU value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e196.25\u0026thinsp;\u0026plusmn;\u0026thinsp;44.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e169.44\u0026thinsp;\u0026plusmn;\u0026thinsp;47.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStatistical Value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003et\u0026thinsp;=\u0026thinsp;3.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP-Value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eP\u0026lt;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eHU Values by Gender and Fracture Stability in Intertrochanteric Fractures.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eFracture Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eStatistical Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStable Fracture\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnstable Fracture\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatients(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHU value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e220.67\u0026thinsp;\u0026plusmn;\u0026thinsp;43.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e182.83\u0026thinsp;\u0026plusmn;\u0026thinsp;56.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.618\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u0026lt;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal HU value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e197.38\u0026thinsp;\u0026plusmn;\u0026thinsp;53.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale (n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatients(n)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHU value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e171.82\u0026thinsp;\u0026plusmn;\u0026thinsp;38.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e146.19\u0026thinsp;\u0026plusmn;\u0026thinsp;46.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.204\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP\u0026lt;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal HU value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e157.99\u0026thinsp;\u0026plusmn;\u0026thinsp;38.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStatistical Value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.971\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.476\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs the population ages, the incidence of osteoporosis-related fractures among the elderly is increasing year on year. On average, an osteoporotic fracture occurs every three seconds, and osteoporosis results in more than 8.9\u0026nbsp;million fractures annually \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Prevention, risk assessment and optimisation of treatment strategies for the two most predominant hip fracture types, femoral neck fracture (FNF) and intertrochanteric femoral fracture (IFF), have been a central theme in orthopaedics. Previous studies have shown that HU values derived from CT scans accurately reflect local bone density and are unaffected by human factors \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Through the present study, we found no significant difference in mean HU values of the femoral head between fractures of the neck of the femur and intertrochanteric fractures. Nevertheless, this finding does not contradict the biomechanical law that severe osteoporosis is the common pathological basis of all hip fragility fractures \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. The specific type of fracture is more likely to be determined by the direction of the force applied during the fall, the severity of the local bone microstructure and anatomical specificity than by the overall bone mineral density of the femoral head alone. This also suggests that, although the HU value of the femoral head is a useful and convenient indicator for assessing the overall bone quality of the hip, it is not sensitive enough to predict the type of proximal femoral fracture.\u003c/p\u003e\u003cp\u003eHowever, it is a strong predictor when assessing the stability of intertrochanteric femoral fractures. Patients with unstable fractures (AO/OTA 31-A2.2 to A3) had significantly lower Hounsfield Unit (HU) values than those with stable fractures (AO/OTA A1.1 to A2.1). This association is intuitive from a mechanical perspective: patients with reduced BMD have reduced trabecular strength and connectivity. Under traumatic loading, this leads to more severe comminution and posterior medial cortical breaks, ultimately resulting in an unstable fracture pattern. This is similar to studies by others \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. This finding provides surgeons with a quantifiable preoperative imaging marker to alert them to a higher likelihood of encountering a complex fracture. This aids preoperative planning and endoprosthesis selection (e.g. standard versus elongated cephalomedullary nails) and improves communication with patients. Furthermore, it may help clinicians anticipate postoperative fracture complications, such as internal fixation failure and screw cut-out.\u003c/p\u003e\u003cp\u003eThis study revealed a significant interaction between gender and fracture stability. It revealed gender dimorphism, consistent with previous studies \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. While HU values were generally higher in males than in females, the decrease in BMD from stable to unstable fractures was more pronounced in males (ΔHU\u0026thinsp;=\u0026thinsp;37.84) than in females (ΔHU\u0026thinsp;=\u0026thinsp;25.63). Notably, the unstable fracture group had the lowest mean absolute HU value in female patients (146.19\u0026thinsp;\u0026plusmn;\u0026thinsp;46.93), which is typically below the threshold commonly used for diagnosing osteoporosis on CT scans. This suggests that, due to accelerated deterioration of bone microarchitecture after menopause and possible concomitant muscle mass loss\u003csup\u003e[\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e, women may be susceptible to unstable fractures at relatively high BMD.\u003c/p\u003e\u003cp\u003eThe most impactful finding of our study was that, despite the clear association between low Hounsfield unit (HU) values, female gender and unstable fracture types, we found no evidence that these factors resulted in worse clinical outcomes in patients undergoing surgical treatment. This finding seems to contradict the extensive historical literature linking osteoporosis to poor fracture fixation outcomes\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. While many previous studies have found that patients with poor bone quality have a worse prognosis\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e, we believe that this negative impact can be effectively overcome with improved techniques and the appropriate use of endografts.\u003c/p\u003e\u003cp\u003eThis study also has some limitations. The retrospective design may be susceptible to selection bias. In this study, we measured the HU value of the femoral head as an indicator of bone mineral density. This could not be measured accurately or directly in the area of the femoral neck or trochanteric fracture due to the fracture itself. This may have influenced the results. Furthermore, we lacked direct assessment of bone microarchitecture (e.g. trabecular bone score), which could provide additional prognostic information beyond density.\u003c/p\u003e\u003cp\u003eIn conclusion, our study suggests that femoral head HU values cannot be used to differentiate between femoral neck and intertrochanteric fractures.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eAll of the following procedures followed the ethical standards of the National Committees on Human Experimentation and the Helsinki Declaration of 1964 and later versions and were approved by the Medical Ethics Committee of Liuzhou Worker\u0026apos;s Hospital. Informed consent was waived because of the retrospective nature of this study according to the Medical Ethics Committee of Liuzhou Worker\u0026apos;s Hospital.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent was obtained from all participants for publication of this result and the accompanying images.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe datasets used or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo funds have been received to support the work.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWenjie Qin: study design, data collection, and interpretation, figures, and article writing. Jiangyun Liao: statistical analysis, data collection. Jianwen Cheng: study design, article editing, and checking the final version. The author(s) read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe would like to express gratitude to all the patients and their families. We also acknowledge the information Department of our hospital for providing support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMcDonough CM, Harris-Hayes M, Kristensen MT, Overgaard JA, Herring TB, Kenny AM, et al. Physical therapy management of older adults with hip fracture. J Orthop Sports Phys Ther. 2021;51(2):CPG1\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDowney C, Kelly M, Quinlan JF. Changing trends in the mortality rate at 1-year post hip fracture - a systematic review. World J Orthop., Johnell O, Kanis JA. (2006). An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporosis International, 17, 1726\u0026ndash;1733.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJohnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006;17(12):1726\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbuAlrob H, Ioannidis G, Jaglal S, Costa A, Griffith LE, Thabane L, et al. Hip fracture rate and osteoporosis treatment in Ontario: A population-based retrospective cohort study. Arch Osteoporos. 2024;19(1):53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen M, Gerges M, Raynor WY, Park PSU, Nguyen E, Chan DH, et al. State of the Art Imaging of Osteoporosis. Semin Nucl Med. 2024;54(3):415\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee SY, Kwon SS, Kim TH, Shin SJ. Is central skeleton bone quality a predictor of the severity of proximal humeral fractures? Injury. 2016;47(12):2777\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePrakash A, Nagakumar JS, Arun SH, Sagar V, Amith K. A Comparative Study of Functional Outcome Following Dynamic Hip Screw and Proximal Femoral Nailing for Intertrochanteric Fractures of the Femur. Cureus. 2022;14(4):e23803.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee KM, Chung CY, Kwon SS, Won SH, Lee SY, Chung MK, et al. Ankle fractures have features of an osteoporotic fracture. Osteoporos Int. 2013;24(11):2819\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00198-013-2366-x\u003c/span\u003e\u003cspan address=\"10.1007/s00198-013-2366-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchreiber JJ, Anderson PA, Rosas HG, Buchholz AL, Au AG. Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Joint Surg Am. 2011;93(11):1057\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePickhardt PJ, Pooler BD, Lauder T, del Rio AM, Bruce RJ, Binkley N. Opportunistic screening for osteoporosis using abdominal computed tomography scans obtained for other indications. Ann Intern Med. 2013;158(8):588\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchreiber JJ, Gausden EB, Anderson PA, Carlson MG, Weiland AJ. Opportunistic Osteoporosis Screening - Gleaning Additional Information from Diagnostic Wrist CT Scans. J Bone Joint Surg Am. 2015;97(13):1095\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWright NC, Looker AC, Saag KG, Curtis JR, Delzell ES, Randall S, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Min Res. 2014;29(11):2520\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChin KY, Soelaiman IN, Naina Mohamed I, Mohamed N, Muhammad N, Wan Ngah WZ. Bone mineral density and trabecular bone score in elderly type 2 diabetes Southeast Asian patients with severe osteoporotic hip fractures. PLoS ONE. 2020;15(11):e0241616.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGautam KP, Cherian KE, Kapoor N, Thomas N, Paul TV. Utility and validation of bone mineral density measurements at forearm in predicting trabecular microarchitecture and central-site osteoporosis in aging Indian postmenopausal women\u0026mdash;a promising surrogate? Aging Med (Milton). 2022;5(1):30\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang YY, Xie N, Sun XD, Nice EC, Liou YC, Huang C, et al. Insights and implications of sexual dimorphism in osteoporosis. Bone Res. 2024;12(1):20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41413-024-00318-8\u003c/span\u003e\u003cspan address=\"10.1038/s41413-024-00318-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSohi YH, Golestani A, Panahi G, TabatabaeiMalazy O, Khalagi K, Fahimfar N, et al. The association between anti-diabetic agents and osteoporosis, sarcopenia, and osteosarcopenia among Iranian older adults; Bushehr Elderly Health (BEH) program. Daru. 2023;32(1):145\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSherly Shulamite N, Pragna Malavika B, Aravinda Swami P. Overview of the Pharmacological Management of Osteoporosis in Postmenopausal Women. J Pharm Res Int. 2021;33(58A):220\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFarshbaf-Khalili A, Malekian S, Efteharsadat B, Ghahremaninasab P, Pourzeinali S. The associations between bone mineral density with body composition parameters in postmenopausal women. Adv Gerontol.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang P, Li Y, Zhuang H, Yu H, Cai S, Xu H, et al. Influence of bone densitometry on the anti-osteoporosis treatment after fragility hip fracture. Aging Clin Exp Res. 2019;31(10):1525\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchreiber JJ, Anderson PA, Hsu WK. Use of computed tomography for assessing bone mineral density. Neurosurg Focus. 2014;37(1):E4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJiang S, Ding Y, Kang L. Impact of sarcopenia on intertrochanteric femoral fracture in the elderly. PeerJ. 2022;10:e13445.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen O, Hu Y, Xu B, Xu W. Impact of combining alfacalcidol with proximal femoral nail antirotation on bone mineral density, serum bone metabolites, and inflammatory markers in elderly patients with osteoporotic intertrochanteric fractures. Ann Ital Chir. 2025;96(9):1180\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hounsfield units, hip fractures, bone density, fracture fixation, osteoporosis","lastPublishedDoi":"10.21203/rs.3.rs-7913552/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7913552/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAs the global population ages, hip fractures have become a significant public health concern. Although computed tomography (CT)-derived Hounsfield units (HU) offer a new perspective for assessing bone density, their value in predicting hip fracture type and stability remains unclear. This study aims to investigate whether femoral head Hounsfield unit (HU) values can distinguish between femoral neck and intertrochanteric fractures, and whether they can be used to predict the complexity of intertrochanteric fractures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA total of 234 hip fracture patients (117 with femoral neck fractures and 117 with intertrochanteric fractures) were selected based on inclusion and exclusion criteria. The mean HU value of the femoral head was measured on preoperative CT images. Based on the AO/OTA classification, intertrochanteric fractures were categorized as either stable (A1.1-A2.1) or unstable (A2.2-A3). Statistical comparisons were performed using independent-samples t-tests, chi-square tests and analysis of variance.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eNo significant difference in overall HU values was observed between the femoral neck fracture group and the intertrochanteric fracture group. However, within the intertrochanteric fracture subgroup, HU values for unstable fractures were significantly lower than for stable fractures. Mean HU values were significantly higher in male patients than in females, with this difference persisting in both stable and unstable fracture groups. The subgroup with the lowest bone density was female patients with unstable fractures.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eAlthough femoral head HU values cannot distinguish between femoral neck and intertrochanteric fractures, they can be used to predict intertrochanteric fracture stability and identify high-risk patients.\u003c/p\u003e","manuscriptTitle":"Could the HU value of the femoral head be used to distinguish between different types of hip fracture, and to predict the severity of intertrochanteric fractures？","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 05:40:42","doi":"10.21203/rs.3.rs-7913552/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e4a4c7ed-8afe-4603-a122-49cc8106407b","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-03T09:54:00+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 05:40:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7913552","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7913552","identity":"rs-7913552","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}