From the Guidelines
To rule out hip fractures, you need to obtain an AP view of the pelvis and a cross-table lateral view of the symptomatic hip, as this combination is the standard approach at many institutions and allows for comparison of potential abnormalities to the contralateral asymptomatic side 1. Specifically:
- AP view of the pelvis
- Cross-table lateral view of the symptomatic hip These views provide a comprehensive assessment of the hip joint and surrounding structures. The AP pelvis view allows comparison with the unaffected side, while the focused hip views offer detailed visualization of the femoral neck, head, and acetabulum. In some cases, additional views may be necessary:
- Frog-leg lateral view: If the patient can't tolerate a true lateral position
- Oblique views: To better visualize certain areas of the hip It's essential to note that X-rays may not detect all hip fractures, especially non-displaced fractures. If clinical suspicion remains high despite negative X-rays, further imaging such as CT or MRI may be warranted, as suggested by the American College of Radiology 1. Proper technique is crucial, ensuring the entire pelvis and both hips are included in the AP pelvis view, and that the affected hip is properly centered and rotated in the focused views for accurate assessment.
From the Research
Radiographic Images for Hip Fracture Diagnosis
To rule out hip fractures, the following radiographic images are necessary:
- Anteroposterior (AP) radiograph of the pelvis 2, 3, 4
- AP view of the hip 2, 3, 5
- Cross-table lateral view of the hip 2, 3, 5, 6
- Traction-internal rotation radiograph of the affected hip may be useful in certain cases, particularly for junior residents to accurately classify proximal femur fractures 2
- Judet views (iliac and obturator) may be helpful in identifying pelvic discontinuity and screw penetration into the hip joint 4, 6
- Computed tomography (CT) scans may be used to confirm the diagnosis of occult hip fractures or to evaluate the extent of the fracture 3, 4, 6
Specific Fracture Types
For specific fracture types, the following images may be necessary:
- Intracapsular fractures: lateral X-ray in addition to AP view may be helpful in detecting displacement 5
- Extracapsular fractures: lateral X-ray may not be necessary for routine assessment 5
- Pelvic discontinuity: a combination of AP pelvis radiograph, true lateral radiograph of the hip, and Judet views may be necessary for accurate diagnosis 4
- Screw penetration into the hip joint: a combination of cross-table lateral view and Judet iliac view may be helpful in diagnosing screw penetration 6