MRI of the Right Hip for Occult Fracture Diagnosis

Clinical Context and Diagnosis

Elderly patients with osteopenia who fall and have hip pain severe enough to prevent ambulation must be assumed to have an occult fracture until proven otherwise, even with negative initial radiographs, according to the American College of Radiology 1, 2
The ability to ambulate with a walker does not exclude fracture—many occult hip fractures, particularly stress or insufficiency fractures, allow limited weight-bearing initially, as noted by the American College of Radiology 1
Phenytoin use is a critical risk factor as it causes accelerated bone loss and significantly increases fracture risk in this population, as highlighted by the American College of Radiology 1

The American College of Radiology gives MRI hip without IV contrast a rating of 9/9 (usually appropriate) for suspected hip stress/insufficiency fracture with negative radiographs, due to its high sensitivity and specificity for detecting occult fractures 1
MRI can identify bone marrow edema patterns that indicate impending or complete fractures requiring urgent intervention, and simultaneously evaluates soft tissue structures that could contribute to pain, as recommended by the American College of Radiology 1, 3

Order MRI hip without IV contrast urgently (ideally within 24-48 hours) for patients with suspected occult hip fracture, as advised by the American College of Radiology and other guidelines 1, 2
Keep patient non-weight-bearing or touch-down weight-bearing only until MRI results are available, to prevent further injury, as recommended by the American College of Radiology 1
Optimize pain control to allow patient comfort while awaiting imaging, as suggested by guidelines 2

Never assume negative radiographs exclude fracture in this high-risk population, and recognize that up to 10% of hip fractures are radiographically occult initially, as warned by the American College of Radiology and other guidelines 1, 2
Do not delay imaging to "see if it gets better" in elderly patients with osteopenia and fall-related hip pain, as this can lead to worse outcomes, as advised by the American College of Radiology 1, 2