What is the best X-ray view to diagnose a hip fracture?

Best X-Ray Views for Hip Fracture Diagnosis

The standard initial imaging for suspected hip fracture should include an anteroposterior (AP) view of the pelvis combined with a cross-table lateral view of the symptomatic hip. 1, 2

Standard Radiographic Protocol

Required Views

• AP pelvis view with approximately 15 degrees of internal rotation 1, 2
• Cross-table lateral view of the symptomatic hip 1, 2
• Some institutions add a separate AP view of the symptomatic hip (three-view series), though no literature directly compares the two-view versus three-view approach 1

Why Both Views Are Essential

The AP pelvis view is critical because:

• Patients with suspected proximal femur fractures frequently have concomitant pelvic fractures (sacrum, pubic rami) that may occur in isolation or alongside hip fractures 1, 2
• It allows comparison with the contralateral asymptomatic side, which is crucial for identifying subtle abnormalities 1, 2

The cross-table lateral view is valuable because:

• It improves overall sensitivity for fracture detection beyond the AP view alone 1
• It can change treatment decisions even when the AP view appears clearly positive 1
• Orthogonal views are considered standard practice for proper fracture characterization 1, 2

Diagnostic Performance and Limitations

Radiographs will identify approximately 90% of proximal femoral fractures, meaning 10% remain radiographically occult. 1, 2 This limitation is critical—negative radiographs alone cannot exclude fracture when clinical suspicion remains high. 1

When Initial Radiographs Are Negative

If radiographs are negative but clinical suspicion persists, MRI without IV contrast is the next imaging study of choice. 1, 3, 2 MRI demonstrates near 100% sensitivity for proximal femoral fracture detection and can confidently exclude fracture, potentially allowing safe discharge from the emergency department. 1, 3

CT without contrast serves as an alternative problem-solving modality when MRI is unavailable, though it is less sensitive than MRI. 1

Common Pitfalls to Avoid

• Never rely on hip radiographs alone without including the pelvis view—this misses associated pelvic fractures that can alter treatment decisions 3, 2
• Never skip the cross-table lateral view even when the AP appears positive, as it improves sensitivity and can change management 1, 3, 2
• Never use ultrasound as initial imaging—it has poor specificity (only 65%) and cannot comprehensively evaluate bones and soft tissues 3
• Never delay advanced imaging when clinical suspicion is high despite negative radiographs—delays in diagnosis increase complications, hospital length of stay, and mortality 3, 2

Special Considerations

In patients where positioning for cross-table lateral views is difficult (severe pain, large body habitus, prior joint replacement, lower limb contractures), modified axiolateral projections may be considered as alternatives, though standard views remain preferred when obtainable. 4

For suspected slipped capital femoral epiphysis specifically, avoid frog-leg lateral views as these can worsen the slip; use cross-table lateral views instead. 5