What are the treatment options for unleveling of the pelvic and femoral structures on an X-ray?

Understanding and Managing Pelvic and Femoral Unleveling on X-ray

Pelvic and femoral unleveling on X-ray typically indicates structural asymmetry that may require further imaging with MRI for accurate diagnosis and appropriate treatment planning. 1

Initial Diagnostic Approach

• The standard radiographic approach for evaluating pelvic and femoral alignment should include an anteroposterior (AP) view of the pelvis with a cross-table lateral view of the symptomatic hip, providing optimal diagnostic information for detecting both hip and pelvic abnormalities 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
• When evaluating unleveling, it's crucial to include the entire pelvis in the imaging to allow comparison with the contralateral side, which serves as an internal control 1, 2

Common Causes of Pelvic and Femoral Unleveling

• Stress fractures (fatigue or insufficiency) of the pelvis, hip, or femur can present with unleveling on X-ray 3
• Developmental dysplasia of the hip may show unleveling due to abnormal acetabular development and femoral head positioning 3
• Avulsion injuries of the pelvic apophyses, particularly in adolescent athletes, can cause asymmetry and unleveling 4
• Anatomical variations in pelvic incidence (PI) can affect the alignment of the lumbar-pelvic-femoral complex 5, 6

Limitations of X-ray in Detecting Unleveling Causes

• Standard radiographs have limitations in sensitivity and specificity for detecting the underlying causes of unleveling 1
• Approximately 10% of proximal femoral fractures are not identified on initial radiographs despite causing asymmetry 1
• Pelvic X-rays have particularly low sensitivity for detecting ischial (10.7%), iliac (28.7%), acetabular (42.4%), and sacral fractures (49.1%) that may contribute to unleveling 7

Advanced Imaging Recommendations

• When X-rays show unleveling but are negative for specific pathology, MRI without IV contrast is the recommended next imaging study 3, 1
• For suspected stress fractures with negative radiographs, MRI without contrast has the highest rating (9/9) for diagnostic accuracy 3
• CT without IV contrast is a reasonable alternative when MRI is contraindicated, with a rating of 7/9 for suspected stress fractures 3
• For suspected extra-articular soft tissue abnormalities causing unleveling, MRI without contrast (9/9) or ultrasound (7/9) are recommended 3

Treatment Considerations Based on Underlying Cause

• For stress fractures causing unleveling, follow-up MRI is recommended to assess healing and guide return to activity decisions 3
• Conservative management is typically successful for avulsion injuries of the pelvis and proximal femur that may present with unleveling 4
• Surgical intervention may be necessary for significant fractures, developmental dysplasia, or other structural abnormalities causing substantial unleveling 3
• Anatomical factors such as low pelvic incidence should be considered when planning surgical interventions, as they may affect outcomes and complication rates 5, 6

Pitfalls to Avoid

• Relying solely on hip radiographs without including pelvis views may miss associated pelvic abnormalities causing unleveling 1, 2
• Failing to obtain orthogonal views can lead to missed diagnoses and potentially altered treatment decisions 1
• Delays in diagnosis and treatment are associated with increased complications, length of hospital stay, and potentially worse outcomes 1
• Overlooking the possibility of occult fractures when radiographs appear normal but clinical symptoms persist 3, 1