Practice Rational imaging

A painful hip

BMJ 2007; 335 doi: (Published 13 September 2007) Cite this as: BMJ 2007;335:563
  1. Philip J O'Connor, consultant musculoskeletal radiologist
  1. Leeds Teaching Hospitals Trust, Leeds LS1 3EX
  1. Correspondence to: P J O'Connor Philip.o'connor{at}

    If you suspect a patient has a fractured hip but radiographs are normal, how else can you confirm this diagnosis?

    Learning points

    • Whenever fractured neck of the femur is suspected on clinical grounds, the patient should be treated for fracture until proved otherwise

    • Normal radiographs (with additional views as appropriate) do not exclude femoral neck fracture—occult fractures comprise about 1% of all fractured necks of femur

    • Before proceeding to further imaging the adequacy of the initial radiographic views must be assessed

    • Magnetic resonance imaging is the method of choice in this situation—it can diagnose occult hip fracture quickly, reliably, and cost effectively

    • Where there is delay in diagnosis or contraindication to magnetic resonance imaging, repeat radiography or scintigraphy may be useful

    The patient

    A previously fit and well 86 year old man presented with acute pain in the left hip after a fall. He had no medical history of note. Hip movement was painful on examination, but no deformity or diagnostic features were present. No fractures were seen on anteroposterior and lateral radiographs of the hip (fig 1).

    Fig 1 Anteroposterior (left) and lateral (right) radiographs of the …

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