Imaging Beyond X-ray for Pain After Hip Pinning

Initial Approach

The American College of Radiology recommends standard radiographs of the hip/pelvis as the essential first-line imaging to evaluate hardware position, fracture healing, and obvious complications after hip pinning 3
If radiographs are negative but clinical suspicion for complications remains high, proceed immediately to cross-sectional imaging, as recommended by the American College of Radiology 1, 2

CT without IV contrast is usually appropriate as the next imaging study after negative or indeterminate radiographs in patients with pain following hip pinning, due to its speed, accessibility, and ability to detect hardware complications, occult fractures, and malposition, as stated by the American College of Radiology 1, 2
CT excels at detecting hardware-related complications, including loosening, malposition, and periprosthetic fractures, with a sensitivity of 94% and specificity of 100% for occult hip fractures, according to the American College of Radiology 3, 1, 2

MRI without IV contrast is usually appropriate when soft tissue injury is suspected, as it is superior for evaluating abductor tendon tears, muscle injuries, or ligamentous damage causing post-pinning pain, as recommended by the American College of Radiology 3, 4, 5
MRI has near 100% sensitivity for occult fractures and detects additional pelvic fractures in 38% of cases, making it a valuable tool for further evaluation when CT is negative but pain persists, according to the American College of Radiology 6

The American College of Radiology recommends obtaining radiographs first to assess hardware position and obvious complications, followed by CT hip without IV contrast if radiographs are negative or indeterminate with persistent pain, and finally MRI hip without IV contrast if CT is negative but pain persists or soft tissue injury is suspected 3, 1, 2, 3, 2

Delaying cross-sectional imaging can reduce morbidity by detecting complications sooner, decreasing immobility time and preventing secondary displacement, as stated by the American College of Radiology 1, 2
Ordering contrast unnecessarily adds cost and risk without diagnostic benefit for most post-pinning complications, according to the American College of Radiology 1, 2, 4