Hip XRay

Aka: Hip XRay, Pelvis XRay, XRay Hip, XRay Hip and Pelvis

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II. Precautions

  1. Hip XRay may miss non-displaced Femoral Fractures
    1. Consider MRI or CT for negative XRay with higher index of suspicion
    2. Parker (1992) Arch Emerg Med 9(1): 23-7 [PubMed]
    3. Hakkarinen (2012) J Emerg Med 43(20: 303-7 +PMID:22459594 [PubMed]

III. Imaging: Views

  1. Standard Views
    1. Anteroposterior Pelvis XRay (AP Pelvis XRay)
    2. Cross-Table Lateral Hip XRay
  2. Hip Avascular Necrosis
    1. Frog-leg Xray
  3. Hip Stress Fracture
    1. Maximal internal rotation hip

IV. Evaluation: Findings

  1. Hip Fracture
    1. Intracapsular Fracture: Femoral Neck Fracture (45 to 53% of all Hip Fractures)
      1. Non-displaced Femoral Neck Fractures are the most commonly initially missed Fractures (9-10%)
      2. Higher risk of AVN, nonunion, malunion or degeneration
        1. Minimal cancellous bone, thin periosteum, poor blood supply
      3. Types
        1. Subcapital Femur Fracture (proximal neck Fracture)
        2. Transcervical neck Fracture (mid-neck Fracture)
    2. Extracapsular Fracture
      1. Intertrochanteric Fracture (38 to 50% of all Hip Fractures)
        1. Good blood supply and largely cancellous bone
        2. Heals well with ORIF
      2. Subtrochanteric Fracture (3% of all Hip Fractures)
        1. Often requires intramedullary rods or nails
        2. Higher risk of impact failure
      3. Femoral Shaft Fracture (or lower Femur Fracture, 5% of all Hip Fractures)
    3. Trochanteric Fracture (Hip Avulsion Fractures in young, active patients)
      1. Greater trochanteric Fracture or Lesser trochanteric Fracture
      2. Treated conservatively with non-weight bearing for 3-4 weeks (unless >1 cm displacement)
  2. Pelvic Fracture
    1. XRay identifies 90% of bony pelvic injuries
    2. Pelvis is a three ringed pretzel (large central inlet, two smaller obturator canals)
      1. Ringed structures typically break in at least two places
      2. When one Pelvic Fracture line is found, identify the other(s)
    3. Evaluate "rings and lines" (comparing to opposite side)
      1. Three pelvic rings
      2. Lines (iliopectineal line, ilioischial line, Shenton line, arcuate line)
      3. Anterior and posterior wall
      4. Acetabulum roof
      5. Pelvic joint widening (SI Joint, Pubic Symphysis)
    4. Additional views (largely replaced by pelvic CT)
      1. Inlet View, Outlet View and Judet View may identify subtle Fractures
  3. Hip Stress Fracture
    1. Frequently missed cause of anterior hip or Groin Pain
    2. Trace medial and lateral cortical margins of the femoral neck
      1. Follow S-shaped curve (where femoral head meets the femoral neck)
      2. Observe for sharp angle along the S-curve suggestive of Stress Fracture
    3. Trace medial (compressive) and lateral (tensile) trabecular lines through femoral shaft and into femoral head
      1. Observe closely for subtle disruptions in trabecular lines suggestive of Stress Fracture
    4. Types
      1. Hip Avulsion Fracture
      2. Femoral Neck Stress Fracture
      3. Femoral Shaft Stress Fracture
      4. Inferior Pubic Ramus Stress Fracture
  4. Hip Dislocation
    1. Posterior Hip Dislocation (90% of dislocations)
    2. Anterior Hip Dislocations (10% of dislocations)
  5. Hip Osteoarthritis
    1. Osteophytes (at acetabulum or femoral head)
    2. Subchondral cysts
    3. Bony sclerosis
  6. Hip Avascular Necrosis
    1. Crescent sign (inconsistently seen on Xray)
      1. Femoral head flattening of the superior aspect
      2. Subchondral Fracture parallel to articular surface
  7. Other findings
    1. Hip lesions (e.g. tumors)

V. References

  1. Shahideh (2013) Crit Dec Emerg Med 27(9):10-18

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