Reading Hip X-rays
From AP pelvis to the fracture you almost miss.
Aug 15, 2026 · 3 refs
At a glance
Hip and pelvis films fail when you stop at the obvious break. Start with an AP pelvis mindset — both hips, the ring, the SI joints — then zoom to the painful side. Occult femoral necks and non-displaced patterns are the ones that create next-day disasters.
Technique pointers
AP pelvis
- Symmetry of obturator rings, iliac wings, SI joints
- Femoral neck trabecular lines; Shenton’s line as a cue, not a religion
- Compare to the contralateral side
Dedicated hip / lateral
- Neck vs intertrochanteric location
- Displacement / Garden thinking for necks
- Soft-tissue clues; prosthesis if present
If pain is high and films look “normal,” escalate imaging rather than discharging hope.
Decision-making
Distinguish femoral neck from intertrochanteric before you call the plan — the operation and urgency counseling differ. Displaced necks in the elderly usually mean arthroplasty discussion; many IT fractures mean fixation.
A vague “hip fracture” handoff is incomplete. Name the region and the displacement.
High-yield / exam
- AP pelvis first for context
- Neck vs IT location changes the operation
- Occult fracture pathway when clinical suspicion is high
- Always compare sides
Questions
On call and Boards items for this topic are coming.
Open the bank →Your pearl
One line you’d tell a junior at 2am.
References
- 01
Imaging of hip fractures and their complications
2014 · Journal of the American Academy of Orthopaedic Surgeons · review
Systematic imaging approach to hip fracture detection and characterization.
- 02
AAOS hip fracture guideline themes relevant to diagnosis and timing
2014 · American Academy of Orthopaedic Surgeons (guidelines / AUC) · guideline
Supports timely diagnosis and surgery pathways for elderly hip fractures.
- 03
OTA teaching on pelvic and hip radiographic evaluation
2019 · Orthopaedic Trauma Association · guideline
Emphasizes AP pelvis context and careful neck/IT distinction.
Related