X-ray Views for Right Hip and Back Pain to Rule Out Fracture
For right hip and back pain, order anteroposterior (AP) view of the pelvis, a dedicated AP view of the symptomatic hip, and a cross-table lateral view of the affected hip to rule out fracture. 1
Hip Radiography Protocol
Standard Views Required
- Anteroposterior (AP) view of the pelvis
- Dedicated AP view of the symptomatic right hip
- Cross-table lateral view of the right hip
This comprehensive approach allows for:
- Proper evaluation of both the hip joint and surrounding structures
- Comparison with the contralateral (left) side
- Detection of concurrent fractures that may be present in the pelvis
Back Pain Radiography Protocol
If back pain is a significant component:
- AP view of the spine in the area of pain
- Lateral view of the spine in the area of pain
The American College of Radiology recommends including at least two views when evaluating for vertebral fractures 1, 2.
Rationale for Imaging Selection
Hip Imaging
- Including the pelvis in hip radiographs is essential as patients with suspected proximal femur fractures often have concurrent fractures of the pelvis, including the sacrum and pubic rami 1
- The AP view of the pelvis with hip radiographs receives the highest rating (9/9) in the American College of Radiology Appropriateness Criteria for hip pain 1
- The AP view should be taken with approximately 15 degrees of internal hip rotation to optimize visualization 1
Back Imaging
- For vertebral fracture assessment, lateral spinal radiographs should be assessed according to the semiquantitative method, with particular attention to Grade II and Grade III fractures 2
- Vertebral fractures are often asymptomatic (>65%) but represent significant risk factors for future fractures 2
Important Clinical Considerations
Limitations of Initial Radiographs
- Negative radiographs alone cannot exclude fracture when clinical suspicion remains high 1
- If initial radiographs are negative but clinical suspicion persists, advanced imaging should be considered:
- MRI without contrast (preferred, 99-100% sensitivity for occult fractures)
- CT scan (alternative when MRI is contraindicated, 79-94% sensitivity)
Reporting Considerations
- Even incidental vertebral fractures should be reported as they indicate increased risk for future fractures 2
- Radiologists should assess for loss of vertebral end-plate parallelism, cortical interruptions, and changes in vertebral body heights 2
By following this protocol, you'll maximize the diagnostic yield while minimizing unnecessary radiation exposure for your patient with right hip and back pain.