Population Covered By The Guidance
This pathway provides guidance on imaging adult patients with suspected hip fracture.
Lead Researcher: Kieran Kusel, Katie Wiwchar
Experts & Contributors: Sven Klinken, Michael Krieser, John Oliver, Pete Tonseth
Date reviewed: April 2021
Date Published: May 2024
Fractured Pubic Ramus
Fractured Acetabulum
Inter-Trochanteric Femoral Fracture
Undisplaced Inter-Trochanteric Femoral Fracture
Sub-Capital Femoral Fracture
- Plain radiographs will show a suspected fracture in the majority of cases
- If clinical suspicion of occult hip fracture persists MRI is the imaging modality of choice
- CT or nuclear medicine bone scan are alternatives to MRI
Date of literature search: April 2013
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Chatha HA, Ullah S, Cheema ZZ. Magnetic resonance imaging and computed tomography in the diagnosis of occult proximal femur fractures. J Orthop Surg (Hong Kong). 2011;19(1):99-103. (Level II evidence)
- Gill SK, Smith J, Fox R, Chesser TJ. Investigation of occult hip fractures: the use of CT and MRI. ScientificWorldJournal. 2013;2013:830319. (Level III evidence)
- Lim KB, Eng AK, Chng SM, Tan AG, Thoo FL, Low CO. Limited magnetic resonance imaging (MRI) and the occult hip fracture. Ann Acad Med Singapore. 2002;31(5):607-10. (Level III evidence)
- Parker MJ. Missed hip fractures. Arch Emerg Med. 1992;9(1):23-7. (Level III evidence)
- Hakkarinen DK, Banh KV, Hendey GW. Magnetic resonance imaging identifies occult hip fractures missed by 64-slice computed tomography. J Emerg Med. 2012;43(2):303-7. (Level III evidence)
- Dominguez S, Liu P, Roberts C, Mandell M, Richman PB. Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial standard radiographs; a study of emergency department patients. Acad Emerg Med. 2005;12(4):366-9. (Level II evidence)
- Kirby MW, Spritzer C. Radiographic detection of hip and pelvic fractures in the emergency department. AJR Am J Roentgenol. 2010;194(4):1054-60. (Level II evidence)
- Kim KC, Ha YC, Kim TY, Choi JA, Koo KH. Initially missed occult fractures of the proximal femur in elderly patients: implications for need of operation and their morbidity. Arch Orthop Trauma Surg. 2010;130(7):915-20. (Level III evidence)
- Lubovsky O, Liebergall M, Mattan Y, Weil Y, Mosheiff R. Early diagnosis of occult hip fractures MRI versus CT scan. Injury. 2005;36(6):788-92. (Level II/III evidence)
- Collin D, Dunker D, Gothlin JH, Geijer M. Observer variation for radiography, computed tomography, and magnetic resonance imaging of occult hip fractures. Acta Radiol. 2011;52(8):871-4. (Level II evidence)
- Pathak G, Parker MJ, Pryor GA. Delayed diagnosis of femoral neck fractures. Injury. 1997;28(4):299-301. (Level II evidence)
- Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995;77(10):1551-6. (Level II evidence)
- Rizzo PF, Gould ES, Lyden JP, Asnis SE. Diagnosis of occult fractures about the hip. Magnetic resonance imaging compared with bone-scanning. J Bone Joint Surg Am. 1993;75(3):395-401. (Level II evidence)
- Rubin SJ, Marquardt JD, Gottlieb RH, Meyers SP, Totterman SM, O'Mara RE. Magnetic resonance imaging: a cost-effective alternative to bone scintigraphy in the evaluation of patients with suspected hip fractures. Skeletal Radiol. 1998;27(4):199-204. (Level III evidence)
- Verbeeten KM, Hermann KL, Hasselqvist M, Lausten GS, Joergensen P, Jensen CM, et al. The advantages of MRI in the detection of occult hip fractures. Eur Radiol. 2005;15(1):165-9. (Level II evidence)
- Quinn SF, McCarthy JL. Prospective evaluation of patients with suspected hip fracture and indeterminate radiographs: use of T1-weighted MR images. Radiology. 1993;187(2):469-71. (Level III evidence)
- Ohishi T, Ito T, Suzuki D, Banno T, Honda Y. Occult hip and pelvic fractures and accompanying muscle injuries around the hip. Arch Orthop Trauma Surg. 2012;132(1):105-12. (Level II evidence)
- Galloway HR, Meikle GR, Despois M. Patterns of injury in patients with radiographic occult fracture of neck of femur as determined by magnetic resonance imaging. Australas Radiol. 2004;48(1):21-4. (Level II evidence)
- Bogost GA, Lizerbram EK, Crues JV, 3rd. MR imaging in evaluation of suspected hip fracture: frequency of unsuspected bone and soft-tissue injury. Radiology. 1995;197(1):263-7. (Level III evidence)
- Sankey RA, Turner J, Lee J, Healy J, Gibbons CE. The use of MRI to detect occult fractures of the proximal femur: a study of 102 consecutive cases over a ten-year period. J Bone Joint Surg Br. 2009;91(8):1064-8. (Level II evidence)
- Oka M, Monu JU. Prevalence and patterns of occult hip fractures and mimics revealed by MRI. AJR Am J Roentgenol. 2004;182(2):283-8. (Level III evidence)
- Frihagen F, Nordsletten L, Tariq R, Madsen JE. MRI diagnosis of occult hip fractures. Acta Orthop. 2005;76(4):524-30. (Level II evidence)
- Dunker D, Collin D, Gothlin JH, Geijer M. High clinical utility of computed tomography compared to radiography in elderly patients with occult hip fracture after low-energy trauma. Emerg Radiol. 2012;19(2):135-9. (Level II/III evidence)
- Cannon J, Silvestri S, Munro M. Imaging choices in occult hip fracture. J Emergency Med. 2009;37(2):144-52. (Review article)
- Deutsch AL, Mink JH, Waxman AD. Occult fractures of the proximal femur: MR imaging. Radiology. 1989;170(1 Pt 1):113-6. (Level III evidence)
- Holder LE, Schwarz C, Wernicke PG, Michael RH. Radionuclide bone imaging in the early detection of fractures of the proximal femur (hip): multifactorial analysis. Radiology. 1990;174(2):509-15. (Level III evidence)
- Evans PD, Wilson C, Lyons K. Comparison of MRI with bone scanning for suspected hip fracture in elderly patients. J Bone Joint Surg Br. 1994;76(1):158-9. (Level III evidence)
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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Plain Radiography
Plain Radiography
Plain radiographs will demonstrate a suspected hip fracture in the majority of patients.
- Will show a suspected fracture in the majority of cases
- May miss some fractures, particularly those that are non-displaced or in patients with osteoporosis
- Reported overall incidence of radiographically occult fractures varies between 2 – 14%
- Lower level of interobserver agreement than CT or MRI
- In patients undergoing MRI for suspected hip fracture, radiographic findings had a false positive rate of 12%
- If clinical suspicion remains high despite normal or equivocal radiographs further imaging should be pursued, as delayed diagnosis increases the rate of secondary fracture displacement and morbidity and is associated with lengthened hospitalisation periods and increased costs ,,,
Magnetic Resonance Imaging (MRI)
Magnetic Resonance Imaging (MRI)
MRI is the preferred imaging modality for patients with suspected radiographically occult hip fracture. Several studies have reported a sensitivity and specificity of 100%. However, MRI is often not immediately available and may be contraindicated in some patients.
- MRI is superior to other imaging modalities in detecting occult hip fractures, , with a reported 100% sensitivity and specificity ,
- Of those patients with suspected hip fracture who undergo MRI, incidence of radiographically occult hip fracture and occult hip and/or pelvic fracture varies widely, and likely depends on MRI requesting criteria ,
- MRI can also detect other causes of pain such as soft tissue injuries and occult pelvic fractures ,,
Computed Tomography (CT)
Computed Tomography (CT)
CT is widely available in emergency departments and is effective for the detection of a suspected occult hip fracture. Several guidelines and studies recommend the use of CT as the next best alternative when MRI is not readily available or is contraindicated.
- Widely available and generally considered effective at diagnosing the occult hip fracture ,
- May miss a small percentage of hip fractures, particularly osteoporotic bone, small impacted fractures or undisplaced fractures that run parallel to the axial plane ,
- Given the importance of timely surgical management, an MRI may be warranted where CT is negative but a high clinical suspicion remains ,
- CT is an alternative when MRI is contraindicated. The shorter acquisition time of CT makes it a useful alternative in elderly and claustrophobic patients who may have motion artefact due to pain or anxiety
Bone Scan
Bone Scan
Highly sensitive for the detection of occult hip fractures, but less specific than MRI
- Although bone scintigraphy is highly sensitive for detection of occult fracture, its lower specificity compared to MRI limits diagnostic utility, often necessitates further advanced imaging, and has been associated with diagnostic and surgical delay ,,
- False positive bone scans have been reported with synovitis, tumours, arthritis and degenerative changes sometimes mimicking fractures ,,
- It may be useful where MRI is contraindicated or not available, or where metallic implants may produce local artefacts and decrease imaging quality on MRI
- Bone scans may be negative in the first 24-48 hours in elderly patients with slow bone turnover or osteoporosis
- There is some debate over the optimal time for doing a bone scan with one study showing it to be accurate within 24 hours of injury but there is a perception that for optimum results it should be delayed for up to 72 hours
Magnetic Resonance Imaging (MRI)
Magnetic Resonance Imaging (MRI)
Several studies have demonstrated the prevalence and clinical significance of occult intertrochanteric extension in radiographically isolated greater trochanteric fractures. MRI is the preferred modality for ruling out these fractures.
- MRI is superior to other imaging modalities in detecting occult hip fractures, , with a reported 100% sensitivity and specificity ,
- Of those patients with suspected hip fracture who undergo MRI, incidence of radiographically occult hip fracture and occult hip and/or pelvic fracture varies widely, and likely depends on MRI requesting criteria ,
- MRI can also detect other causes of pain such as soft tissue injuries and occult pelvic fractures ,,
Magnetic Resonance Imaging (MRI)
Magnetic Resonance Imaging (MRI)
MRI is warranted where CT scan is negative but clinical suspicion for fracture remains.
- MRI is superior to other imaging modalities in detecting occult hip fractures, , with a reported 100% sensitivity and specificity ,
- Of those patients with suspected hip fracture who undergo MRI, incidence of radiographically occult hip fracture and occult hip and/or pelvic fracture varies widely, and likely depends on MRI requesting criteria ,
- MRI can also detect other causes of pain such as soft tissue injuries and occult pelvic fractures ,,