skip to main content

Occult hip fracture — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

HardHip and GroinOccult hip fractureMSRA

A 79-year-old woman is reviewed in a same-day assessment unit 18 hours after falling from standing height at home. She landed on her right side and has persistent deep right groin pain. Initial anteroposterior pelvis and lateral hip radiographs at a minor injuries unit were reported as adequate and normal. She remains unable to weight-bear despite paracetamol and oral morphine. There is no leg shortening or external rotation, but passive hip rotation and axial loading reproduce her groin pain. She is haemodynamically stable and has no neurological deficit. She has a non-MR-conditional spinal cord stimulator. What is the most appropriate next investigation?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Perform urgent CT of the hip and pelvis to assess for an occult fracture

Explanation lettering: D = shown as A · E = shown as C · A = shown as D · C = shown as E

This patient has continuing clinical suspicion of hip fracture despite adequate normal radiographs: she has sustained a low-energy fall, has persistent focal groin pain, and remains unable to weight-bear with pain on passive rotation and axial loading. The absence of shortening or external rotation does not exclude an occult intracapsular or intertrochanteric fracture. NICE recommends MRI when hip fracture is suspected despite negative adequate radiographs. However, CT should be considered when MRI is contraindicated or unavailable within 24 hours. Her non-MR-conditional spinal cord stimulator makes MRI inappropriate; urgent CT is therefore the best next investigation. A is unsafe because delayed repeat radiography can postpone diagnosis and definitive management of a potentially unstable fracture. C would normally be the preferred investigation, but is contraindicated in this case. D was historically used for occult fractures but is not the NICE alternative to MRI and is less useful for urgent decision-making. E may identify a hip effusion but cannot reliably exclude an occult proximal femoral fracture.

Reference: NICE CG124: Hip fracture: management, Recommendations, section 1.1 Imaging options in occult hip fracture (Last updated 6 January 2023) — https://www.nice.org.uk/guidance/cg124/chapter/recommendations NICE CG124 Hip fracture full guideline, section 5 Imaging options in occult hip fracture (2025 resource publication) — https://www.nice.org.uk/guidance/cg124/resources/hip-fracture-full-guideline2