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Occult hip fracture — MSRA MCQ

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ModerateMRIOccult hip fractureMSRA

An 81-year-old woman is assessed in the emergency department 3 hours after tripping on a rug and falling onto her left side at home. She has persistent groin pain and is unable to weight-bear. She has pain on attempted straight-leg raise and on axial loading of the left leg. There is no limb shortening or external rotation. An anteroposterior pelvis radiograph and lateral radiograph of the left hip are of adequate quality and show no fracture. The orthopaedic team considers an occult hip fracture likely. She has no contraindication to MRI, but the earliest MRI appointment is 30 hours after admission. What is the most appropriate next imaging plan?

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

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Correct answer: C — Arrange CT of the left hip today

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

A is correct. She has continuing clinical suspicion of hip fracture despite adequate negative radiographs: she cannot weight-bear and has persistent groin pain with provocative examination findings after a low-energy fall. NICE recommends MRI for suspected occult hip fracture after negative adequate X-rays. However, where MRI is not available within 24 hours, CT should be considered. As her MRI cannot occur until 30 hours after admission, CT today is the appropriate next investigation. B would be correct if MRI were available within 24 hours, because MRI is NICE's preferred investigation for occult hip fracture. C may appear attractive because some initially occult fractures become radiographically evident later, but it would unnecessarily delay diagnosis, analgesia planning and definitive management. D was historically used for occult fractures, but NICE identifies CT, rather than bone scintigraphy, as the alternative when timely MRI is unavailable or contraindicated. E does not reliably exclude an occult intracapsular or nondisplaced proximal femoral fracture and is not the recommended pathway.

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