What are the indications and management for a right femur x-ray (x-ray of the right femur)?

Right Femur X-Ray: Indications and Management

X-ray of the right femur should be obtained as the first-line imaging study for evaluating hip/femoral pain, suspected fracture, or structural abnormalities, with an anteroposterior (AP) view of the pelvis combined with a cross-table lateral view of the affected hip being the standard protocol. 1

Initial Imaging Protocol

The correct order is an AP pelvis view PLUS a cross-table lateral view of the right hip—never order isolated femur/hip views without including the pelvis. 2, 3

Technical specifications:

• AP pelvis with 15 degrees internal rotation to properly align the femoral neck and minimize lesser trochanter visibility 3
• Cross-table lateral view of the symptomatic right hip to complete orthogonal imaging 1, 3
• Include the entire pelvis to allow comparison with the contralateral side, which serves as an internal control 2

Critical pitfall to avoid:

Never accept frog-leg lateral views in trauma settings as they risk displacing occult fractures; always use cross-table laterals 3

Primary Indications for Right Femur X-Ray

Acute trauma scenarios:

• Suspected fracture after fall or minor trauma - radiographs detect most proximal femoral fractures and should be obtained first 1
• Hip pain following low-force trauma - identifies fractures, dislocations, and concomitant pelvic injuries 3

Chronic pain evaluation:

• Chronic hip/thigh pain - radiographs screen for arthritis, bone tumors, dysplasia, and femoroacetabular impingement 1
• First-line test for osteoarthritis - physical examination plus radiography may be superior to MRI for this diagnosis 1

Special populations:

• Patients on long-term bisphosphonates (3-5 years) with thigh/groin pain - evaluate for atypical femoral fractures with characteristic lateral cortex thickening ("beaking") 1
• Consider imaging the contralateral femur as bilateral involvement occurs in up to 30% of atypical fractures 1

Management Based on Initial X-Ray Results

When radiographs are positive:

• Fractures identified: Proceed with appropriate orthopedic consultation and surgical planning 1
• Atypical fracture features present: Look for transverse fracture line originating at lateral cortex, minimal comminution, and periosteal thickening 1
• Arthritis or structural abnormalities: Guide conservative vs. surgical management based on severity 1

When radiographs are negative but clinical suspicion persists:

Approximately 10% of proximal femoral fractures are not visible on initial radiographs despite causing symptoms. 2, 3

Order MRI without IV contrast as the next imaging study - this is the highest-rated modality (9/9) with near 100% sensitivity for radiographically occult fractures 1, 2

MRI advantages:

• 99-100% sensitivity for detecting occult proximal femoral fractures 1
• Detects stress fractures, bone marrow edema, and soft tissue injuries 1, 2
• Characterizes fracture morphology to guide conservative vs. surgical treatment 1
• Rapid coronal STIR sequence alone has 100% sensitivity and can be completed quickly for elderly patients who tolerate long scans poorly 1

Alternative if MRI contraindicated:

CT without IV contrast (rated 7/9) is reasonable for detecting lucency in incomplete fractures and excluding neoplastic pathology 1, 2

For patients on long-term bisphosphonates with negative radiographs:

MRI is the primary utility to determine radio-occult stress changes and define cortical involvement extent, which determines conservative vs. surgical treatment 1

• Consider contralateral MRI scanning even if contralateral radiograph appears normal 1
• Bone scintigraphy is a second-line diagnostic test 1

Common Diagnostic Pitfalls

• Relying on hip-only views without pelvis imaging misses associated pelvic pathology and eliminates contralateral comparison 2, 3
• Failing to obtain orthogonal views leads to missed diagnoses and altered treatment decisions 2, 3
• Overlooking occult fractures when radiographs appear normal but symptoms persist—maintain high clinical suspicion and proceed to MRI 2, 3
• Delays in diagnosis are associated with increased complications, longer hospital stays, and worse outcomes 2

Specialized Views (Limited Role)

A traction-internal rotation radiograph may improve fracture classification accuracy by junior physicians, particularly for distinguishing femoral neck from intertrochanteric patterns, though this is not standard practice 4

Additional specialized views (false profile, Dunn view) can evaluate dysplasia or femoroacetabular impingement but have not replaced the standard AP/lateral protocol 1