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

Hip and Femur X-rays for Suspected Hip Fractures

For patients with suspected hip fractures, both hip and pelvis X-rays should be performed as the standard radiographic approach, including an anteroposterior (AP) view of the pelvis with a cross-table lateral view of the symptomatic hip. 1

Standard Imaging Protocol

• The American College of Radiology recommends a comprehensive approach that includes both pelvis and hip views to provide optimal diagnostic information and detect both hip and pelvic fractures 1
• Orthogonal views are essential for proper diagnosis, typically consisting of:
  • An AP view of the pelvis with approximately 15 degrees of internal rotation 1
  • A cross-table lateral view of the affected hip 1, 2

Rationale for Combined Imaging

• Patients with clinically suspected proximal femur fractures often have concomitant pelvic fractures (including sacrum and pubic rami), making comprehensive imaging crucial 1
• Including the pelvis in radiographic assessment allows for comparison with the contralateral asymptomatic side, which significantly improves diagnostic accuracy 1
• Relying solely on hip radiographs without pelvis views may result in missed associated pelvic fractures, potentially leading to altered treatment decisions 1

Clinical Presentation and Imaging Correlation

• Patients with hip fractures typically present with groin pain and inability to bear weight on the affected extremity 2
• Displaced fractures present with external rotation and abduction, with the affected leg appearing shortened 2
• Despite being the first-line imaging approach, approximately 10% of proximal femoral fractures may not be identified on initial radiographs 1

Follow-up Imaging When Initial X-rays Are Negative

• When radiographs are negative but clinical suspicion remains high, MRI without IV contrast is the recommended next imaging study 1, 3
• MRI has proven valuable in diagnosing occult hip fractures, with studies showing that 37% of MRIs performed for suspected hip fractures with negative X-rays confirm the presence of fractures 3

Clinical Implications and Pitfalls

• Delays in diagnosis and treatment are associated with increased costs, complication rates, longer hospital stays, and higher short- and long-term mortality 1
• Failing to obtain orthogonal views can lead to missed fractures and potentially altered treatment decisions 1
• In certain clinical scenarios (significant pain, large patient habitus, limited range of motion), obtaining proper positioning for a cross-table lateral view may be challenging, requiring consideration of alternative imaging approaches 4

Special Considerations

• In cases where proper positioning is difficult due to patient factors, a modified axiolateral hip projection may be considered as an alternative to the standard cross-table lateral view 4
• Patients with suspected but unproven hip fractures who require cross-sectional imaging often have multiple medical comorbidities, with studies showing that 54% of such patients have concomitant medical discharge diagnoses 5