Should both hip and femur (femoral) X-rays be performed in cases of suspected hip fracture?

Hip and Femur X-rays for Suspected Hip Fracture

For suspected hip fractures, both pelvis and hip X-rays should be performed, including an anteroposterior (AP) view of the pelvis along with orthogonal views of the symptomatic hip, as this combination provides optimal diagnostic information and allows for detection of both hip and pelvic fractures. 1

Initial Imaging Protocol

• The standard radiographic approach should include an AP view of the pelvis with a cross-table lateral view of the symptomatic hip 1
• Some institutions include three views: an AP view of the pelvis, a separate AP view of the symptomatic hip, and a cross-table lateral view 1
• Orthogonal views are essential for proper diagnosis, typically consisting of an AP view with approximately 15 degrees of internal rotation and a cross-table lateral view 1

Rationale for Combined Imaging

• Patients with clinically suspected proximal femur fracture often have concomitant fractures of the pelvis, including the sacrum and pubic rami 1
• Pelvic fractures may occur in isolation or together with proximal femur fractures, necessitating comprehensive imaging 1
• The inclusion of a pelvis radiograph allows for comparison of potential abnormalities to the contralateral asymptomatic side 1

Limitations and Follow-up Imaging

• Despite being the mainstay for initial imaging, both pelvis and hip radiographs have limitations in sensitivity and specificity for fracture detection 1
• Negative radiographs alone cannot exclude fracture; approximately 10% of proximal femoral fractures will not be identified on initial radiographs 1
• When radiographs are negative but clinical suspicion remains high, MRI without IV contrast is the recommended next imaging study 1

Special Considerations

• In cases where proper positioning for a cross-table lateral view is difficult due to pain, large patient habitus, or pre-existing conditions limiting lower limb mobility, a modified axiolateral hip projection may be considered as an alternative 2
• Delays in diagnosis and treatment are associated with increased cost, complication rates, length of hospital stay, and short- and long-term mortality, making accurate initial imaging crucial 1

Common Pitfalls to Avoid

• Relying solely on hip radiographs without including pelvis views may miss associated pelvic fractures 1
• Assuming a negative radiograph excludes fracture when clinical suspicion remains high 1
• Failing to obtain orthogonal views, which can lead to missed fractures and potentially altered treatment decisions 1