ANATOMY

PROXIMAL FEMUR
Consists of four essential parts:
• Head
• Neck
• Greater trochanter
• Lesser trochanter

Head of the femur is rounded and smooth for Greater trochanter is a large
articulation with the hip bones. Contains a prominence that is located
depression, or pit, near its center called the superiorly and laterally to the
fovea capitis. femoral shaft and is palpable as a
bony landmark.
 PROXIMAL FEMUR
Lesser trochanter is a smaller, blunt,
conical eminence that projects medially and
posteriorly from the junction of the neck and
shaft of the femur.

Trochanters are joined posteriorly by a thick

ridge called intertrochanteric crest.

Angle of the neck to the shaft on an average

adult is approximately 125°, with a variance
of ±15°
Longitudinal plane of the femur is about 10° 15° to 20° anterior angle of the head
from vertical. and neck in relation to the body of the
femur.
 PELVIS
Pelvis serves as a base for the trunk and a
girdle for the attachment of the lower limbs.

Consists of: Two hip bones. the sacrum. and

the coccyx.

Pelvic girdle - composed of only the two hip

bones.

Hip bone is often referred to as:

Os Coxae
Innominate Bone
 HIP BONE
Composed of three divisions:
• Ilium
• Ischium
• Pubis
• Each ischium is divided into a body and a
ramus.
Ilium is the largest of the three divisions.

Ischium is located inferior and posterior Acetabulum is a deep, cupshaped cavity

to acetabulum. that accepts the head of the femur to
form the hip joint.
Pubis is located inferior and anterior to
acetabulum.
 HIP BONE

The two superior rami meet in the

midline to form an amphiarthrodial joint,
the symphysis pubis.

Obturator foramen is a large opening

formed by the ramus and body of each
ischium and by the pubis.
Body of the pubis is anterior and inferior
to the acetabulum and includes the
anteroinferior one-fifth of the
acetabulum.
 TRUE VS. FALSE
General area superior to the oblique plane
through the pelvic brim is termed the
GREATER, OR FALSE, PELVIS.

Pelvic brim is defined by the superior

portion of the symphysis pubis anteriorly
The area inferior to a plane through the and by the superior, prominent part of the
pelvic brim is termed THE LESSER, OR sacrum posteriorly
TRUE, PELVIS.

The true pelvis is a cavity that is

completely surrounded by bony
structures.
 INLET VS. OUTLET

The oblique plane defined by the brim The outlet, or inferior aperture, of the
of the pelvis is termed the inlet, or true pelvis is defined by the two ischial
superior aperture, of the true pelvis. tuberosities and the tip of the coccyx
MALE VS. FEMALE
LOCALIZATION

Determine the midpoint of a line

between the ASIS and the symphysis
pubis.

The head is approximately 1.5 inches

(3 to 4 cm)

The neck is approximately 2.5 inches

(6 to 7 cm)
LOCALIZATION

The level of the symphysis pubis is

between 3 and 4 inches (8 to 10 cm)
inferior to the level of the ASIS.

Femoral neck can be readily located as

being 1 to 2 inches (3 to 5 cm) medial
and 3 to 4 inches (8 to 10 cm) distal to
the ASIS.
 PELVIS AND
UPPER FEMORA
AP PROJECTION
PxP: Supine
PP: Unless contraindicated, medially
rotate the feet 15 – 20 degrees to place
the femoral neck parallel to the film.

- Heels should be 8-10 inches apart.

CR: ┴ to IR (midway of ASIS and Pubic
Symphysis) 2” inferior to ASIS and 2”
superior to pubic symphysis
SS: head, neck, trochanters, and proximal
one third or one
fourth of the shaft of the femora.
AP PROJECTION
SS: Head, neck, trochanters, and proximal
one third or one fourth of the shaft of the
femora.
AP PROJECTION
(Martz and Taylor)
Used to demonstrate 1st Projection
relationship of femoral head to CR: perpendicular to Pubic Symphysis
acetabulum in patient with
-For detection of lateral and superior
congenital hip dislocation.
displacement of femoral head.

2nd Projection
CR: 45 degrees Cephalad
- For anterior (B) or posterior (C)
displacement of the femoral head (A).
LATERAL PROJECTION
PxP: Lateral recumbent / Dorsal decubitus

PP: MCP centered and ┴ to IR

- ASIS lying in same vertical plane.

Berkebile et al. (DD)

- “gull-wing” sign in cases of fracture-
dislocation of acetabulum and posterior
dislocation of femoral head.

CR: ┴ to level of soft tissue just above the

greater trochanter
AXIAL PROJECTION
(Chassard – Lapine Method)
For measuring the transverse CR: ┴ to LS
biischial diameter. junction at the
level of greater
To determine the relationship of
femoral head to acetabulum. trochanters

To demonstrate opacified PxP: Patient seated on the end of the

rectosigmoid. radiographic table.
Thighs are abducted
Lean directly forward until symphysis pubis is in
close contact with the table
Vertical axis of the pelvis will be tilted forward
approximately 45 degrees.
FEMORAL NECKS
AP OBLIQUE PROJECTION
(Modified Cleaves Method)
1. Have the patient flex hips
and knees, draw feet up as
much as possible. Ask the
px. to be still while adjusting
the X-ray tube.
2. Center the IR 1 inch
superior to the pubic CR: ┴ 1” superior to pubic symphysis
symphysis.
Unilateral – femoral neck
3. Abduct* thighs as much as
possible and px’s feet
turned inward.
*45 degrees from vertical if
possible
AXIOLATERAL PROJECTION
(Cleaves Method)
SAME PART POSITION AS
MODIFIED CLEAVES

SS: Femoral necks without

superimposition from
greater trochanters
CR: (||) with the femoral shafts – may vary
from 25 to 45 degrees
CONGENITAL HIP
DISLOCATION
(Andren & von Rosen Method)
Bilateral hip projection

Both legs are forcibly

abducted to at least 45
degrees

Internally rotated and

extended Knake and Kuhns
Described a device
Describes longitudinal
to aid in positioning
relationship between
long axis of the femur for the Andren-von
and acetabulum Rosen hip view,
HIP
AP PROJECTION
PxP: Supine

PP: Unless contraindicated, medially

rotate the feet 15 – 20 degrees to place
the femoral neck parallel to the film.

CR: ┴ to femoral neck

SS: head, neck, trochanters, and proximal
one third of the body of the femur.
LATERAL PROJECTION
(Lauenstein & Hickey Methods)
PxP: Supine
PP: Knee is flexed and thigh is drawn up to
a position nearly at right angle to the hip
bone.
Keep the body of the affected femur
parallel to the table.
Contraindicated for
CR: Lauenstein - ┴ to hip joint
fractures and pathologic
Femoral neck overlapped by the greater
condition.
trochanter
Hickey – 20-25 degrees cephalad
Similar to Modified Cleaves
AXIOLATERAL PROJECTION
(Danelius-Miller Method)
PxP: Supine
PP: Adjust the patient to be able to center the
most prominent part of the greater trochanter to
the midline of the IR.

Flex and elevate the unaffected leg.

IR is vertical and parallel to femoral neck.

Projection for trauma, surgery,
Unless contraindicated, affected leg is internally and postsurgery patients, as
rotated 15-20 degrees well as for other patients who
cannot move or rotate the
CR: ┴ to femoral neck affected leg for frog-leg lateral
AXIOLATERAL PROJECTION
(Clements-Nakayama Modification)
PxP: Supine
PP: Adjust the patient so that the affected side is
near the edge of the table.

No rotation of the limb

IR is parallel to femoral neck and back is tilted 15

degrees.
Projection for bilateral trauma,
surgery, and postsurgery
CR: 15 degrees posteriorly
patients.
If there is limitation of
movement of the unaffected leg
AXIOLATERAL PROJECTION
(Friedman Method)
PxP: Lateral recumbent

PP: MCP parallel to the midline of the

table

Roll upside limb 10 degrees posteriorly

CR: 35 degrees cephalad Contraindicated for

fractures and pathologic
Kisch – 15 to 20 degrees cephalad condition.
PA OBLIQUE PROJECTION
(Hsieh Method)
Projection for demonstrating posterior
dislocations of the femoral head in cases
other than acute fracture dislocations.

PxP: Semiprone; resting on the affected

side

PP: Elevate the unaffected CR: ┴ IR between posterior surface of the

side 40 to 45 degrees iliac blade and the dislocated femoral
head.
AP OBLIQUE PROJECTION
(Urist Method)
Projection for demonstrating posterior
rim of the acetabulum in acute fracture
dislocation injuries of the hip.
PxP: Supine
PP: Elevate injured hip 60 degrees to
place the posterior ream of acetabulum in
profile.
CR: ┴ to the midpoint of the IR
MEDIOLATERAL OBLIQUE PROJECTION
(Lilienfeld Method)
PxP: Lateral recumbent on the affected
side

PP: MCP parallel to the midline of the

table

Roll upside limb 15 degrees forward

Contraindicated for
CR: ┴ to the midpoint of the IR fractures and pathologic
condition.
MEDIOLATERAL OBLIQUE PROJECTION
(Colonna Method)
Separate the shadows of the hip joints
and gives the optimum projection of the
slope of the acetabular roof and the depth
of the socket.

PxP: Lateral recumbent on the unaffected

side
For patients with acute hip
PP: MCP parallel to the midline of the injury
table
CR: ┴ to the midpoint of
Roll upside limb 17 degrees forward the IR
ACETABULUM
PA AXIAL OBLIQUE PROJECTION
(Teufel Method)
The resulting image shows the fovea
capitis and particularly the
superoposterior wall of the acetabulum.

PxP: Semiprone on the affected side

PP: Center hip being examined on the CR: 12 degrees cephalad –

grid. inferior level of coccyx and
approx. 2” lateral to the
Elevate the unaffected side to form 38 MSP of side examined.
degree angle from the anterior of the
body to the table.
AP OBLIQUE PROJECTION
(Judet Method)
Useful in diagnosing fractures of the
acetabulum using two oblique positions.

PxP: Semisupine; 45 degrees rotation.

➢ Internal oblique (affected side up)

Iliopubic (anterior) column and posterior
rim of acetabulum
CR: ┴ - 2” below the ASIS of the affected
side.
AP OBLIQUE PROJECTION
(Judet Method)
Useful in diagnosing fractures of the
acetabulum using two oblique positions.

PxP: Semisupine; 45 degrees rotation.

➢ External oblique (affected side down)

Ilioischial (posterior) column and anterior
rim of acetabulum.
CR: ┴ to pubic symphysis
ANTERIOR PELVIC BONES
PA PROJECTION
PxP: Prone

PP: Center MSP to midline of the grid.

Center IR at the level of GT. This position

also centers the IR to the pubic
symphysis.

CR: ┴ to IR – enters distal coccyx and

exits the pubic symphysis

SS: PS, ischia, and obturator foramina

AP AXIAL “OUTLET” PROJECTION
PxP: Supine

PP: Center MSP to midline of the grid.

CR/RP: 2” distal to the superior pubic

symphysis
MALE:
20-35 degrees cephalad
FEMALE:
30-45 degrees cephalad
SS: Rami without foreshortening as seen
in AP or PA projections.
SUPEROINFERIOR AXIAL “INLET” PROJECTION
(Lilienfeld Method)
PxP: Seated upright / Supine
PP: Center MSP to midline of the grid.
Seated: Flex the knees and provide
support to relieve strain.
✓ Lean backwards 45-60 degrees to
place pubic arch in vertical position.
✓ IR centered at the level of GTs
CR: ┴ to IR centered 1 ½ “ superior to PS
Supine: 40 degrees caudad
SS: Medially superimposed superior and
inferior rami of pubic bones.
PA AXIAL “INLET” PROJECTION
(Staunig Method)
PxP: Prone

PP: Center MSP to midline of the grid.

CR: 35 degrees cephalad SS: Same with Lilienfeld method.

exiting the PS on the MSP Rami without foreshortening as seen in AP
anteriorly at the level of GT. or PA projections.
ILIUM
AP & PA OBLIQUE PROJECTIONS
PxP: Supine

PP/SS: Center sagittal plane passing

through the hip joint of the affected side.
Rotation: 40 degrees – Unaffected side
RPO/LPO POSITIONS: Broad surface of the
wing of affected ilium parallel to IR.

RAO/LAO POSITIONS: Affected ilium

perpendicular to the IR in profile

CR: ┴ to the midpoint of the IR