Proximal femoral morphometry and its association with hip fracture patterns: a systematic review with meta-analysis

Abstract Purposes Proximal femoral fractures (PFFs) represent a major cause of morbidity and mortality in the elderly population. Beyond bone mineral density, proximal femoral (PF) and hip joint (HJ) morphometry have been implicated in fracture susceptibility and fracture pattern. However, the relative contribution of individual geometric parameters remains incompletely defined. The purpose of this study was to systematically evaluate the association between PF and HJ morphometry and hip fracture (HF) patterns, and to assess the predictive value of radiographic morphometric parameters derived from standard anteroposterior radiographs. Materials and methods A systematic review with meta-analysis was conducted in accordance with PRISMA guidelines. PubMed and MEDLINE databases were searched up to September 2025 for observational studies reporting radiographic morphometric parameters in patients with unilateral PFFs. Statistical meta-analysis was performed with random-effect models to compare intracapsular-ICF/subcapital-SCF fractures with intertrochanteric (ITF) and extracapsular (ECF) fracture patterns. Results Twenty-two studies comprising 4184 patients (77.8% female; pooled mean age 77.4 years) were included. Meta-analysis using a random-effects model revealed that ITF were significantly associated with a smaller femoral head diameter ( p < 0.001) and increased medial neck cortex thickness ( p = 0.021) compared with ICF. ECF demonstrated significantly longer femoral neck axis length ( p = 0.012), increased horizontal offset ( p = 0.048), smaller absolute offset ( p = 0.026) and shorter hip axis length ( p = 0.026) than ICFs. Angular parameters provided the most robust stratification. ITFs and ECFs exhibited significantly lower (more varus) neck-shaft angles ( p < 0.001) and significantly higher Wiberg angles ( p < 0.001) compared with the ICF group. Conclusions PF and HJ morphometry are associated with distinct HF patterns, independently of bone mineral density. Simple linear and angular measurements obtained from standard anteroposterior radiographs may assist fracture pattern stratification, risk assessment, and preoperative planning in elderly patients.