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Radiographically occult hip fracture — SCE Rheumatology MCQ

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ModerateHip and GroinRadiographically occult hip fractureSCE Rheumatology

A 74-year-old woman with polymyalgia rheumatica has taken oral prednisolone for 4 years. She develops sudden severe right groin pain after twisting while stepping off a kerb. She did not fall but has subsequently been unable to bear weight. There is marked pain on axial loading and passive internal rotation of the hip. She is afebrile, with no focal greater trochanteric tenderness. An anteroposterior pelvic radiograph and an adequate cross-table lateral hip radiograph show no fracture. The reporting radiologist considers the films technically satisfactory. MRI is not available for 36 hours, whereas multidetector CT can be performed immediately. Which imaging plan is most appropriate now?

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

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Correct answer: D — Computed tomography of the hip today

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

The acute groin pain, inability to bear weight and pain on axial loading and hip rotation maintain a high clinical suspicion of proximal femoral fracture despite technically adequate negative radiographs. Her age and prolonged glucocorticoid exposure further increase fragility-fracture risk. NICE recommends MRI when hip fracture remains suspected after adequate negative radiographs. However, when MRI cannot be obtained within 24 hours, CT should be considered. Because MRI would be delayed for 36 hours and CT is immediately available, CT today is the best next investigation (C). Bone scintigraphy (A) is slower and is not the NICE-preferred alternative to MRI. Repeating radiographs after 48 hours (B) risks delaying diagnosis and definitive management in a patient with persistent high-risk features. MRI (D) would be preferred if it were available within 24 hours; it would also be appropriate after a negative CT if strong clinical suspicion persisted, because MRI has greater diagnostic accuracy for occult fracture. Ultrasonography (E) may identify an effusion or guide aspiration but cannot reliably exclude a femoral-neck fracture.

Reference: Hip fracture: management (CG124) — Recommendations (Last updated 6 January 2023) — https://www.nice.org.uk/guidance/CG124/chapter/recommendations Comparison of CT and MRI in diagnosing occult hip fracture: a systematic review and meta-analysis (15 July 2024) — https://pubmed.ncbi.nlm.nih.gov/39114706/