Hip (Clements-Nakayama view)

Mr Andrew Murphy et al.

The Clements-Nakayama view of the hip is a highly specialised lateral projection utilised on patients with bilateral femoral fractures, or patients unable to mobilise due to postoperative requirements. When performed correctly the projection can yield images of a high diagnostic quality comparable to the horizontal beam lateral hip.

This projection can also be utilised to image the femoral shaft in the setting of bilateral femoral fractures (see figure 1).

The projection was first described in 1980 as a method to image patients after total hip arthroplasty.

  • patient is supine with the side of interest close to the edge of the table
  • arms are placed on the chest
  • image receptor is held in a detector stand and placed in landscape above the illiac crest of the affected side
  • ensure the detector is running parallel to the femoral neck (this can be calculated on the AP pelvis projection)
  • axiolateral projection
  • centring point
    • the central ray is projected inferiorly superiorly from the opposite side of the affected limb
    • there is a 15 posterior angle centred at the region of the femoral neck. Note, this angle is a guide and further angle is frequently required
    • the mediolateral angle is changed to accommodate align to the femoral neck
  • collimation
    • anteroposterior 9 cm each direction from the midline
    • inferosuperior 12 cm each direction from the centring point
       
  • orientation  
    • landscape
       
  • detector size
    • 24 x 30 cm (however this will vary with NOF vs. femoral shaft)
       
  • exposure
    • 80-90 kVp
    • 80-150 mAs (highly dependent on patient habitus)
  • SID
    • 100-150 cm
       
  • grid
    • a grid can be used, although it is not uncommon to utilise an air gap technique to achieve similar results

The radiograph has a uniform exposure throughout, evident by the fine bony detail and no areas of overexposure. If the distal femur is overexposed, then a filter may be required.

The lesser trochanter can be seen in profile, while the proximal femoral shaft superimposes the greater trochanter.

The femoral neck is central to the image and shows no signs of radiographic foreshortening or elongation.

There is a clear visualisation of the articular surface of the acetabulum and the head of the proximal femur.

This is one of the harder projections in trauma imaging to master, it is used infrequently and requires a higher level of skill than standard hip views. Something to consider when setting up for a Clements-Nakayama view is the patient's soft tissue volume, patients with a higher proportion require a steeper posterior angle to clear the other leg.

The posterior angle is necessary to achieve a true lateral hip, however, be wary of any metal on the table that may project onto the image. This is why the patient should be as close as safely possible to the edge of the table closest to the detector.

The best way to approach the examination would be to consider this projection similar to a shoot through hip, however, you are angling down rather than raising the leg.

Radiographic views
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Article Information

rID: 53099
Section: Radiography
Synonyms or Alternate Spellings:

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Cases and Figures

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    Figure 1: Clements-Nakayama view (femoral shaft)
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    Figure 1: Clements-Nakayama view (neck of femur)
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