What imaging should be ordered for an elderly patient with a possible hip fracture and intact sensation in the affected extremity?

Initial Imaging for Suspected Hip Fracture

Order an anteroposterior (AP) view of the pelvis combined with a cross-table lateral view of the affected hip as your initial imaging study. 1, 2

Standard Radiographic Protocol

The presence or absence of sensation in the extremity does not change the imaging approach for suspected hip fracture. The American College of Radiology (ACR) 2024 guidelines establish the following as the standard initial imaging:

• AP pelvis view with approximately 15 degrees of internal hip rotation 1
• Cross-table lateral view of the symptomatic hip 1
• Some institutions include a separate AP view of the affected hip in addition to the pelvis view, though there is no specific literature comparing these two approaches 1

Use cross-table lateral rather than frog-leg lateral views due to the potential risk of fracture displacement with frog-leg positioning 1

Why Include Both Views

The combined pelvis and hip imaging approach is critical because:

• Concomitant pelvic fractures occur frequently - patients with suspected proximal femur fractures often have associated fractures of the pelvis, sacrum, and pubic rami 1, 2
• Comparison to the contralateral side is essential for identifying subtle abnormalities 1, 2
• Orthogonal views are mandatory for proper fracture detection and classification 1

Limitations and Next Steps

Despite being first-line imaging, radiographs have important limitations:

• Approximately 10% of proximal femoral fractures are not identified on initial radiographs 1, 2
• Negative radiographs alone cannot exclude fracture when clinical suspicion remains high 1

If Radiographs Are Negative But Clinical Suspicion Persists:

Order MRI of the pelvis and affected hip without IV contrast as the next imaging study 1, 2

• MRI demonstrates near 100% sensitivity for proximal femoral fractures 1, 2
• MRI also detects associated pelvic fractures and soft tissue injuries 1

CT without IV contrast is an alternative if MRI is contraindicated or unavailable, though it is less sensitive than MRI 1

• CT is faster to obtain than MRI and can be useful when rapid diagnosis is critical 1
• Patients with negative or equivocal CT may still require MRI if clinical suspicion persists 1

Critical Timing Considerations

Delays in diagnosis significantly increase morbidity and mortality:

• Surgical delays beyond 12 hours are associated with increased 30-day mortality 1
• Rapid diagnosis reduces complications, hospital length-of-stay, and costs 1, 2
• Radiographs can be performed portably in the trauma bay without moving the patient 1

Common Pitfalls to Avoid

• Do not rely solely on hip radiographs without including the pelvis view, as this misses associated pelvic fractures 2, 3
• Do not skip the cross-table lateral view - orthogonal views are essential and can change treatment decisions 1, 2
• Do not use ultrasound as initial imaging - it has poor specificity (only 65%) for fracture detection 3
• Do not order bone scan - there is no evidence supporting its use as initial or follow-up imaging for acute traumatic hip pain 1
• Do not order contrast-enhanced imaging (CT or MRI with IV contrast) - there is no role for contrast in the initial evaluation 1