Initial X-ray for Hip Pain
For patients presenting with hip pain, the initial radiographic evaluation should include an anteroposterior (AP) view of the pelvis and a cross-table lateral view of the symptomatic hip. 1
Standard Radiographic Protocol
Primary Views
Anteroposterior (AP) view of the pelvis
- Allows visualization of both hips for comparison
- Helps identify pelvic fractures that may occur alongside hip pathology
- Provides assessment of potential abnormalities compared to contralateral side
Cross-table lateral view of the symptomatic hip
- Provides orthogonal perspective necessary for complete evaluation
- AP view alone is insufficient for comprehensive assessment
- Helps detect fractures not visible on AP view
Optional Additional View
- Some institutions include a separate AP view of the symptomatic hip in addition to the above views 1
Rationale for This Approach
This approach is supported by strong evidence showing that patients with suspected proximal femur fractures often have concurrent pelvic fractures, including those of the sacrum and pubic rami 1. The cross-table lateral view is particularly important as it:
- Changes treatment decisions in some cases even when AP view is clearly positive
- Improves overall sensitivity of radiographic evaluation
- Provides critical information about fracture morphology 1
Clinical Considerations
Suspected Fractures
- Radiographs detect approximately 90% of proximal femoral fractures
- If radiographs are negative but clinical suspicion remains high, MRI without contrast is the recommended next step 1, 2
- MRI has nearly 100% sensitivity for detecting occult hip fractures 2
Other Hip Pathologies
- For chronic hip pain where initial radiographs are negative, MRI without contrast is recommended for evaluation of:
Common Pitfalls to Avoid
- Inadequate views: Obtaining only an AP view without the cross-table lateral view may miss fractures and lead to misdiagnosis 1
- Poor technique: The AP view should be taken with approximately 15 degrees of internal rotation for optimal visualization 1
- Premature advanced imaging: MRI should be reserved for cases where radiographs are negative but clinical suspicion remains high 1, 2
- Overlooking pelvic pathology: Failing to include the pelvis in the initial radiographic assessment may miss associated pelvic fractures 1
Special Considerations
For cases where fracture classification remains difficult after standard views, some institutions utilize a physician-assisted traction-internal rotation radiograph, which has been shown to improve accuracy of fracture classification, particularly by less experienced physicians 4.