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Occult hip fracture — MSRA MCQ

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HardHip and GroinOccult hip fractureMSRA

An 84-year-old woman is assessed in the emergency department after tripping on a doorstep and landing on her left side. Before the fall, she mobilised independently with a frame. She has persistent deep left groin pain and is unable to weight-bear despite paracetamol and oral morphine. Examination shows pain on axial loading and passive internal rotation of the left hip. There is no deformity, neurovascular deficit or focal lumbar tenderness. An anteroposterior pelvis radiograph and lateral hip radiograph are of adequate quality and show no fracture. She has a legacy non-MRI-conditional pacemaker, confirmed by the cardiology device service. CT is available immediately. 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 — Request CT of the pelvis and left hip

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

This presentation should be managed as a suspected occult hip fracture: she has a fragility-type fall, persistent groin pain, pain on hip loading and rotation, and inability to weight-bear despite adequate normal radiographs. A normal initial radiograph does not exclude a proximal femoral fracture. NICE recommends MRI when hip fracture remains suspected despite negative adequate X-rays. However, MRI is contraindicated here because she has a confirmed non-MRI-conditional pacemaker. NICE therefore advises CT as the alternative when MRI is contraindicated or unavailable within 24 hours. CT should be obtained urgently rather than arranging delayed community reassessment. A is inappropriate because delayed repeat radiography risks ongoing pain, immobility and delayed fracture treatment. B may detect increased bone turnover but is not the NICE-recommended alternative to MRI in this acute diagnostic pathway. C would ordinarily be first-line for occult fracture, but the implanted device makes it unsuitable in this case. D does not adequately assess an occult femoral neck or intertrochanteric fracture.

Reference: NICE CG124: Hip fracture: management — Recommendations, section 1.1 Imaging options in occult hip fracture (Updated January 2023) — https://www.nice.org.uk/guidance/cg124/chapter/recommendations