The most common injury by far in the pelvis / hip area is the fractured neck of femur (NOF). Mostly in the older generation and predominantly female. Generally due to decalcification and degeneration due to the aging process making the bones weaker.

There are generally five different types of NOF fractures, dependent on where the fracture is. The management in general is to replace the proximal femur with a hip prosthesis for subcapital fractures, (except in children), and to repair the hip for the other types of NOF fracture.

The fracture line passes across the neck of femur just distal to the head of femur. Image 4 shows the transcervical with displacement, image 5 shows an impacted transcervical.

Most common is the fracture of the greater trochanter, see image 7. The fracture of the lesser trochanter is seen less often hence no image at present. These can be particularly difficult to see with poorly positioned A.P. views.

The most common pelvic fractures are probably those of the pubic and ischeal ramii. Again these tend to be associated with the older generation. Image 8 shows a fracture of the pubic ramus. With the obturator foramen being a ring structure it is common to have more than one fracture site. In other words, if a fractured pubic ramus is seen check carefully for a fracture of the ischeal ramus, and vice versa. Image 9 shows a fracture of the ischeal ramus.

There are three quite rare adolescent fractures, these being avulsions of the ischeal tubercle apophysis, the anterior superior iliac spine and the anterior inferior iliac spine. The strong femoral muscles are attached at these points, sartorius at the A.S.I.S., rectus femoris at the A.I.I.S., adductor magnus and hamstring at the ischeal tubercle. These avulsions tend to be caused by strenuous exercise of the leg, ie. kicking a football. Image 10 shows the avulsed ischeal tubercle with image 11 showing the normal appearance. Image 12 shows an avulsed A.I.I.S.. Image 13 shows an avulsed A.S.I.S.

Fractures of the ileum are usually easy to see until they involve the S.I. joints where there can be some confusion. Image 14 shows a diastasis of the right S.I. joint. On image 15, a closer view, it can be seen that there is also a fracture of the ileum.

Fractures across the acetabulum can be tricky to see and usually require good Judet views (45 degree obliques) to show them. Images 16 to 18 are a set of radiographs from a patient who suffered a pelvic trauma, and Judet views were used to assess the injuries. Image 16 is the straight A.P. showing the fracture through the acetabulum. Images 17 and 18 are the Judet views which were used to assess the acetabular fracture. Image 17 is the affected side rotated 45 degrees to the film and shows the acetabulum in profile, and it can be seen that this shows the fracture through the acetabulum quite well. Image 18 is the affected side rotated 45 degrees away from the film and shows the acetabulum "on face" which shows the fracture across it.

Images 19 and 20 are a good example of the importance of the Judet view. Image 19 is part of an AP pelvis of a man who had been hit on the left side by a car. It was noticed that there was a bony fragment lying adjacent to the superior lip of the acetabulum. It looks to be an os acetabulare but as it was unilateral, combined with the history, it was decided to do Judet views. Image 20 shows a fracture through the acetabulum however it does not appear to communicate with the original fragment which is likely to be a normal variant after all, and had it not been there the fracture would probably have gone unnoticed. Just occasionally luck plays a part.

Images 21 to 23 are from another pelvic trauma series. Image 21 is the straight A.P. showing the fracture of both pubic and both ischeal ramii. Image 22 is the "angle up" view demonstrating the same fractures. Image 23 is the "angle down" again demonstrating the same fractures but also showing a rather nasty fragment protruding posteriorly which affected the bladder.

Image 24 is of a patient who had no history of trauma. She has got severe degeneration which has got worse over recent months, it can be seen that the joint space is severely diminished. She has ended up with a fracture of the superior acetabular lip due to wear and tear. Compare this image to image 29 of an os acetabulare.

Not so much variants but plain normal, images 25 to 28 show the normal epiphyseal / apophyseal lines of the paediatric hip and pelvis. Note in image 25 , the separated lesser trochanter, the apophyseal line of the greater trochanter, the epiphyseal line of the head of femur and the unfused acetabulum. Image 26, the apophyseal line of the greater trochanter. Image 27, the apophyseal line of the iliac crest. Image 28 shows the suture between the pubic and ischeal ramii. Do not mistake these for fractures!