How do I order a standard hip X‑ray (anteroposterior pelvis and lateral view) for an adult patient with acute groin/thigh/buttock pain, limited range of motion, inability to bear weight after trauma, suspected fracture, and a history of osteoporosis and prior hip surgery?

How to Order a Hip X-ray for Suspected Fracture

Order an anteroposterior (AP) view of the pelvis with approximately 15 degrees of internal hip rotation plus a cross-table lateral view of the symptomatic hip as your initial imaging study. 1, 2

Standard Initial Imaging Protocol

The two-view combination is the established standard:

• AP pelvis view with 15 degrees of internal rotation 3, 2
• Cross-table lateral view of the affected hip 3, 1, 3

Some institutions add a third view (separate AP of the symptomatic hip), though there is no specific literature comparing the two-view versus three-view approach 3

Why This Specific Combination Matters

The AP pelvis view is essential because:

• Patients with suspected proximal femur fractures often have concomitant pelvic fractures (sacrum, pubic rami) that occur in isolation or with femoral fractures 3
• It allows comparison with the contralateral asymptomatic side, which is crucial for accurate diagnosis 3, 2
• It may reveal pathology beyond the symptomatic hip that changes management 2, 4

The cross-table lateral view is critical because:

• It improves overall sensitivity for fracture detection beyond the AP view alone 3
• It changes treatment decisions in a subset of patients even when the AP view appears positive 3
• It is preferred over frog-leg lateral views in trauma cases due to lower risk of fracture displacement 2

Ordering Instructions

Write the order as: "X-ray hip, 2 views: AP pelvis and cross-table lateral of [left/right] hip" or "X-ray pelvis and hip: AP pelvis with cross-table lateral of symptomatic hip" 3, 1, 2

Request portable imaging if the patient:

• Cannot safely be moved due to pain or instability 1, 4
• Has suspected fracture requiring immobilization 4

Critical Pitfall to Avoid

Never order only hip views without the pelvis view – this misses associated pelvic fractures in a substantial proportion of patients and may lead to incomplete diagnosis and inappropriate treatment planning 3, 2

When Initial Radiographs Are Negative But Suspicion Remains High

If radiographs are negative or equivocal but clinical suspicion for fracture persists:

• Order MRI hip without IV contrast as the next study, which has near 100% sensitivity for proximal femoral fractures 3, 2, 4
• Alternatively, order CT hip without IV contrast if MRI is contraindicated or unavailable, though CT is less sensitive (79-94% sensitivity) 1

The rationale for advanced imaging:

• At least 10% of proximal femoral fractures are radiographically occult 3
• In patients with negative radiographs but persistent clinical concern, 24-39% will have occult fractures on advanced imaging 1
• Delays in diagnosis increase mortality, complication rates, hospital length-of-stay, and costs 1, 2, 4

Special Considerations for Your Patient

Given the history of osteoporosis and prior hip surgery:

• Radiographs remain the appropriate first-line study 3, 1, 2
• Hardware from prior surgery may complicate interpretation but does not change the initial imaging approach 2
• The threshold for proceeding to MRI should be low if radiographs are negative, given the high-risk profile 1, 4

Given the acute presentation with inability to bear weight:

• Imaging should be obtained urgently to enable prompt treatment and reduce morbidity 1, 2, 4
• Surgical delay beyond 12 hours significantly increases 30-day mortality in patients over 50 with hip fractures 4