Imaging Guidelines for Traumatic Hip Pain in the Elderly

Initial Imaging and CT Indications

Plain radiographs (AP pelvis and lateral hip) are the first-line imaging modality for all elderly patients with acute traumatic hip pain after a fall, as recommended by the American College of Radiology 1, 4
The American College of Radiology suggests that CT hip without IV contrast is indicated when plain radiographs are negative or indeterminate but clinical suspicion for hip fracture remains high, to reduce fracture-related morbidity and mortality in elderly patients 1, 2, 3
CT hip without IV contrast detects occult hip fractures in 24.1% of patients with negative radiographs and changes management in 20% of cases, according to the American College of Radiology 1, 5, 6

The American College of Radiology recommends using CT hip WITHOUT IV contrast only, as there is no evidence supporting CT with IV contrast or CT without and with IV contrast for acute traumatic hip pain evaluation 1, 2, 3
CT has 94% sensitivity and 100% specificity for detecting radiographically occult hip fractures, as reported by the American College of Radiology 1, 2, 3

Rapid diagnosis reduces morbidity and mortality by decreasing length of immobility, reducing risk of osteonecrosis, and enabling surgery within 24-48 hours, which significantly reduces short-term and mid-term mortality, according to the American College of Radiology 1, 2, 3
The American Academy of Orthopaedic Surgeons notes that preventing complications from delayed treatment is crucial, and that isolated greater trochanter fractures may be managed non-operatively if no femoral neck extension 7

The American College of Radiology advises against relying on clinical signs alone to exclude fracture, and against increasing the number of radiographic projections instead of proceeding to CT, as this does not decrease the need for cross-sectional imaging 1, 5, 6
The American College of Radiology also recommends against using bone scan, as there is insufficient evidence for bone scan in acute traumatic hip pain evaluation 1, 2, 3