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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

Ortho Skills (Real Life) and Boards items for this topic are coming.

References

  1. 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.

    PubMed search →
  2. 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.

    PubMed search →
  3. 03

    OTA teaching on pelvic and hip radiographic evaluation

    2019 · Orthopaedic Trauma Association · guideline

    Emphasizes AP pelvis context and careful neck/IT distinction.

    PubMed search →

From the Journal

Films and cases live in the long-form. The Xray Reading Course is the full system.

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