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Occult hip fracture — MSRA MCQ

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ModerateHip and GroinOccult hip fractureMSRA

A 79-year-old woman presents to her GP surgery after tripping on a kerb 2 days ago. She landed on her left side and has since had persistent left groin pain. She can stand only with assistance and is unable to take four steps because of pain. There is no head injury, fever or preceding atraumatic hip pain. An anteroposterior pelvic radiograph and lateral left hip radiograph obtained at an urgent treatment centre yesterday were reported as normal. On examination, she has pain on passive hip internal rotation and axial loading. There is no shortening or external rotation of the leg. She has a non-MRI-conditional permanent pacemaker. What is the most appropriate next step?

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

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Correct answer: A — Arrange same-day hospital assessment for CT to assess for an occult hip fracture

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

This woman has continuing clinical suspicion of hip fracture despite adequate normal radiographs: she has persistent groin pain after a low-energy fall, cannot weight-bear and has pain on passive hip rotation and axial loading. Absence of leg shortening or external rotation does not exclude an undisplaced intracapsular fracture. NICE recommends MRI when hip fracture remains suspected after negative adequate X-rays. However, MRI is contraindicated here because her pacemaker is non-MRI-conditional. NICE therefore advises considering CT as the alternative when MRI is contraindicated or unavailable within 24 hours. She requires same-day hospital assessment because an occult femoral neck fracture may displace if missed and mobilised. A is inappropriate because physiotherapy and attempted mobilisation risk worsening an unrecognised fracture. B may detect later radiographic change but delays definitive assessment in a patient unable to weight-bear. C does not reliably exclude an occult proximal femoral fracture. D was historically used for occult fractures, but NICE identifies CT, rather than radionuclide bone scanning, as the appropriate alternative to MRI in current NHS practice.

Reference: NICE CG124: Hip fracture: management — Recommendations, imaging options in occult hip fracture (Last updated 6 January 2023) — https://www.nice.org.uk/guidance/cg124/chapter/recommendations