Standard Hip Radiographs
For initial evaluation of hip pathology, obtain an anteroposterior (AP) view of the pelvis with 15 degrees of internal hip rotation and a cross-table lateral view of the affected hip 1.
Standard Two-View Series
The ACR Appropriateness Criteria (2025) establishes this as the gold standard initial imaging approach 1:
- AP pelvis view: Provides assessment of hip symmetry and bilateral comparison
- Cross-table lateral view of affected hip: Preferred over frog-leg lateral due to risk of fracture displacement with frog-leg positioning 1
- 15-degree internal rotation: Should be applied during AP imaging to optimize visualization 1
Clinical Context Matters
For Acute Traumatic Hip Pain
The standard AP and cross-table lateral views are specifically designed to detect fractures and dislocations rapidly, reducing morbidity by minimizing immobility time and osteonecrosis risk 1. These can be performed portably in the trauma bay without moving the patient 1.
For Chronic Hip Pain/Osteoarthritis
An AP pelvis radiograph remains first-line imaging 2. The lateral view selection depends on clinical indication:
- Lequesne's false profile view: Particularly valuable for assessing osteoarthritis 2
- Lauenstein view: Alternative lateral projection for specific indications 3
Critical Pitfall to Avoid
Never order a frog-leg lateral view in acute trauma settings - this positioning risks displacing occult fractures 1. The cross-table lateral eliminates this risk while providing equivalent diagnostic information.
When Initial Radiographs Are Negative
If clinical suspicion for fracture persists despite negative or indeterminate radiographs, CT without IV contrast is the next appropriate study due to its speed advantage over MRI in detecting radiographically occult fractures 1. MRI becomes necessary only if CT remains negative or equivocal with persistent clinical concern 1.