Is the pelvis included on a standard x-ray of the femur (thigh bone) and hip?

Standard X-ray of Femur and Hip Includes the Pelvis

Yes, a standard x-ray of the femur and hip should include the pelvis, as recommended by the American College of Radiology (ACR) guidelines. 1, 2

Standard Radiographic Protocol

• The ACR recommends a standard hip x-ray evaluation protocol that includes:

  • An anteroposterior (AP) view of the pelvis
  • A dedicated AP view of the symptomatic hip
  • A cross-table lateral view of the affected hip 1, 2

• This comprehensive approach ensures proper evaluation of both the hip joint and surrounding structures, allowing for comparison with the contralateral side 1, 2

Clinical Rationale for Including the Pelvis

• Patients with suspected proximal femur fractures often have concurrent fractures of the pelvis, including the sacrum and pubic rami 1
• These pelvic fractures may occur in isolation or together with proximal femur fractures 1
• Including the pelvis allows for comparison of potential abnormalities to the contralateral asymptomatic side, improving diagnostic accuracy 1, 2

Diagnostic Benefits

• The AP view of the pelvis with the hip radiographs is considered complementary, receiving the highest rating (9/9) in the ACR Appropriateness Criteria for chronic hip pain 1
• For acute hip pain with suspected fracture, the ACR specifically recommends including the AP pelvis view along with orthogonal views of the symptomatic hip 1
• This approach is the standard at many institutions, ensuring comprehensive evaluation 1

Technical Considerations

• The AP view should be taken with approximately 15 degrees of internal hip rotation to optimize visualization 2
• In cases of suspected fracture, a cross-table lateral view is preferred over the frog-leg lateral view to avoid potential fracture displacement 2

Important Caveats

• Even with proper technique including pelvis views, radiographs have limitations in sensitivity and specificity for fracture detection 1
• Negative radiographs alone cannot exclude fracture when clinical suspicion remains high 1
• If initial radiographs are negative but clinical suspicion for fracture persists, advanced imaging such as MRI without contrast (preferred) or CT should be considered 1, 2

By following this standardized approach that includes the pelvis in femur and hip radiographs, clinicians can maximize diagnostic accuracy and improve patient outcomes through appropriate and timely treatment decisions.