When would you order an X-ray (X-radiation) of a hip wound?

X-ray Indications for Hip Wounds

X-rays of hip wounds should be ordered when there is suspicion of foreign bodies, underlying fractures, joint involvement, infection, or penetrating trauma, as these findings significantly impact morbidity and mortality outcomes.

Primary Indications for Hip Wound X-rays

Trauma-Related Indications

• Penetrating injuries (gunshot wounds, stab wounds, impalement)

  • Critical to assess for bullet fragments, foreign bodies, and bone damage 1
  • Helps determine trajectory and structures at risk
  • Assists in medicolegal documentation

• Suspected fractures

  • When clinical examination suggests underlying bone injury
  • For patients with history of falls and hip pain/limited mobility 2
  • When wound is near bony prominences (greater trochanter, iliac crest)

• Foreign body detection

  • When history suggests retained foreign material
  • For wounds with unclear mechanism or contamination

Infection-Related Indications

• Signs of deep infection

  • Persistent drainage or purulent discharge
  • Progressive erythema and swelling extending beyond wound margins
  • Systemic signs of infection with localized hip pain

• Suspected osteomyelitis

  • For chronic non-healing wounds
  • When there's exposed bone or deep probing to bone
  • In immunocompromised patients with hip wounds

Joint Involvement Concerns

• Suspected joint space involvement
  • When wound is in proximity to hip joint
  • For detection of lipohemarthrosis (indicating intra-articular fracture) 2
  • To evaluate for joint effusion or air in joint space

Imaging Protocol for Hip Wounds

Initial Assessment

• Standard views for hip wound evaluation:

  • Anteroposterior (AP) view of pelvis
  • Cross-table lateral view of affected hip 2
  • Additional focused views of the wound area as needed

• The American College of Radiology recommends:

  • Never omit the cross-table lateral view, even when AP shows a fracture 2
  • Always include the pelvis in initial imaging to avoid missing associated injuries 2

Advanced Imaging Considerations

• When initial X-rays are negative but clinical suspicion remains high:
  • MRI without contrast is recommended (99-100% sensitivity for occult fractures) 2
  • CT scan if MRI is contraindicated or unavailable 2

Special Circumstances

Gunshot Wounds

• Always obtain X-rays for gunshot wounds to:
  • Locate bullet fragments
  • Assess bone damage
  • Determine trajectory
  • Document findings for medicolegal purposes 1

Chronic Hip Wounds

• Consider X-rays when:
  • Wound fails to heal despite appropriate treatment
  • Suspicion of underlying osteomyelitis
  • Concern for pathologic fracture in chronically ill patients

Pediatric Considerations

• For children with hip wounds:
  • Lower threshold for imaging due to difficulty in obtaining reliable exam
  • Consider developmental issues like developmental dysplasia of the hip 2
  • Be aware that cartilaginous injuries may not be visible on X-ray 3

Clinical Pitfalls to Avoid

• Delaying imaging in high-risk scenarios can lead to increased complications, longer hospital stays, and higher mortality rates 2

• Relying solely on X-rays when clinical suspicion is high - remember that occult hip fractures may not be visible on initial X-rays 4

• Failing to include the pelvis in initial assessment, potentially missing associated pelvic fractures 2

• Not obtaining proper orthogonal views (both AP and lateral), which provide complementary information 2

By following these guidelines, clinicians can appropriately utilize X-ray imaging for hip wounds to improve diagnosis, treatment planning, and ultimately patient outcomes.