Occult Hip Fractures in Older Adults: When a Normal X-ray Isn’t Enough After a Fall

A fall from standing height that leads to groin pain or an inability to walk is never “just a bruise” in an older adult. Up to one in ten hip fractures can be radiographically occult—meaning the initial X-rays look normal even though the bone is cracked. Missed or delayed diagnosis increases the risk of prolonged pain, loss of independence, and medical complications that raise mortality. Early recognition and the right second test—usually magnetic resonance imaging—prevent many of these harms. ^[1]

“Occult” hip fractures are breaks of the proximal femur that are not visible on standard radiographs taken soon after the injury. They are most commonly incomplete femoral neck fractures or nondisplaced intertrochanteric fractures in osteoporotic bone. Because alignment is preserved and mineral content is low, the crack line may be too subtle to see on X-ray—especially within the first hours after injury. Magnetic resonance imaging can detect bone marrow edema and tiny fracture lines long before radiographs change. ^[2]

• New groin or lateral hip pain that worsens with standing or pivoting
• Inability to bear weight or a new limp that does not improve with simple analgesia
• Pain with gentle hip rotation (for example, passive log-roll test)
• Night pain or pain at rest
• True mechanical symptoms—the patient tries but cannot take steps

When these are present, do not be reassured by a normal radiograph. Guidelines advise urgent advanced imaging to confirm or exclude an occult hip fracture. ^[3]

Radiographs are the right first test for acute hip pain, but sensitivity drops for nondisplaced fractures and in demineralized bone. Early after injury, fracture lines may be hair-thin; trabecular disruption is hard to appreciate; and overlying bowel gas or suboptimal patient positioning can obscure details. Multiple consensus statements emphasize that when suspicion remains high, magnetic resonance imaging should follow, because it sees marrow edema and microtrabecular injury that X-rays cannot. ^[3]

Obtain anteroposterior pelvis and lateral hip radiographs as the initial study. If these show a displaced fracture, proceed to orthopedic management. If they are negative or equivocal but clinical concern persists, move to advanced imaging.^[3]

The National Institute for Health and Care Excellence recommends magnetic resonance imaging within 24 hours when a hip fracture is suspected despite normal hip X-rays; if magnetic resonance imaging is unavailable within 24 hours or contraindicated, computed tomography is reasonable. ^[4]

The latest American College of Radiology Appropriateness Criteria note that noncontrast computed tomography is usually appropriate as the first-line test after negative or indeterminate radiographs, especially when magnetic resonance imaging is not readily available. However, if clinical concern persists after a negative computed tomography, magnetic resonance imaging is still required because it can reveal fractures that computed tomography misses. ^[5]

Bottom line: Both computed tomography and magnetic resonance imaging are useful, but magnetic resonance imaging is the most sensitive test for occult hip fractures and should be obtained when doubt remains. Meta-analyses and comparative studies repeatedly show higher sensitivity and specificity for magnetic resonance imaging. ^[6]

Bone scintigraphy can detect increased turnover at fracture sites; however, it often requires 24–72 hours to turn positive and is generally not preferred when magnetic resonance imaging or computed tomography are available quickly in the emergency setting. Modern guidelines therefore place bone scans as a second-line option in resource-limited contexts. ^[7]

• Magnetic resonance imaging: No radiation; detects bone marrow edema early; best at finding incomplete femoral neck fractures and distinguishing fractures from soft-tissue injuries. Downsides include availability, time, and contraindications (for example, certain implants or severe claustrophobia). Multiple studies and meta-analyses confirm that magnetic resonance imaging has superior sensitivity and specificity for occult hip fractures compared with computed tomography. ^[6]
• Computed tomography: Widely available and quick; excellent for cortical breaks and for surgical planning when a fracture is already known; modern multidetector scanners perform well, but small or incomplete fractures can still be missed—especially early after injury—so a negative computed tomography does not always end the workup if symptoms strongly suggest a fracture. ^[8]

Radiology reference cases demonstrate exactly this problem: some intertrochanteric or femoral neck fractures are invisible on radiographs and even computed tomography, yet are clearly identified by magnetic resonance imaging. ^[2]

Hip fractures in older adults are sentinel events. Professional societies recommend surgery within 24–48 hours of admission when a fracture is confirmed, because earlier surgery is associated with lower mortality, fewer complications (such as pneumonia, thromboembolism, and pressure injuries), and faster return to mobility. Every day of delay can compound risk. ^[9]

When fractures are missed because advanced imaging is not obtained despite ongoing red flags, patients often return with worsened displacement, intractable pain, and declining function—turning a potentially straightforward fixation into a more complex operation with higher risks. ^[10]

• Adults over 65 years—especially women—with osteoporosis or low bone mineral density
• Those on long-term corticosteroids or other medicines that weaken bone
• Patients with dementia or neuropathy who cannot fully describe pain yet demonstrate new inability to walk
• Individuals with a low-energy mechanism (simple trip or slip) and persistent groin pain despite normal films

In these groups, guidelines emphasize low threshold for magnetic resonance imaging or computed tomography after negative radiographs. ^[3]

1. Careful exam: Pain with gentle internal or external rotation, a positive log-roll test, or pain on axial loading.
2. Initial radiographs: Standard views to look for obvious fracture, dislocation, or deformity.
3. Advanced imaging: Magnetic resonance imaging (preferred) or computed tomography to identify nondisplaced femoral neck or intertrochanteric fractures. Magnetic resonance imaging often reveals associated injuries (for example, pelvic insufficiency fractures, muscle tears) that explain pain if no hip fracture is present. ^[11]
4. Orthopedic consult: If a fracture is found, a surgeon discusses operative options and timing.

Evidence-based recommendations from orthopedic societies and national guidelines converge on expedited surgery, ideally within 24–48 hours, accounting for medical optimization and resource realities. This time window lowers mortality and complications. ^[9]

• Nondisplaced femoral neck fractures: Often treated with internal fixation (for example, screws or a sliding hip device) to prevent displacement and allow early mobilization.
• Displaced femoral neck fractures in frail older adults: Frequently managed with hemiarthroplasty or total hip arthroplasty to reduce reoperation rates and allow faster recovery.
• Intertrochanteric fractures: Typically fixed with cephalomedullary nails or sliding hip screws, depending on fracture pattern and bone quality.

While specific implants and decisions are individualized, the principle is universal: stabilize the fracture quickly so the patient can get out of bed, mobilize, and breathe deeply—the best prevention against hospital complications. ^[12]

Multimodal pain strategies (acetaminophen, limited opioids, regional anesthesia where appropriate) plus early physical therapy shorten hospital stays and improve function. Protocol-driven care bundles are often included in hip fracture pathways endorsed by professional guidelines. ^[12]

When magnetic resonance imaging or computed tomography excludes a fracture, consider:

• Pelvic insufficiency fractures (pubic rami, sacral ala)
• Hip contusions, muscle or tendon tears, and greater trochanteric bursitis
• Lumbar radiculopathy referring pain to the groin

Magnetic resonance imaging often identifies these mimics and helps target the right treatment (for example, protected weight-bearing for pelvic fractures, physical therapy for soft-tissue injury). ^[11]

Whether an occult fracture is found or excluded, a fall serious enough to raise suspicion signals high future risk. Good care includes:

• Osteoporosis assessment and treatment (bone mineral density testing, calcium and vitamin D guidance, and prescription therapies when indicated)
• Medication review to reduce sedatives and adjust blood pressure medicines to prevent dizziness
• Vision and footwear checks; home hazard reduction (lighting, rugs, bathroom bars)
• Strength and balance training through supervised physical therapy or community programs

These steps reduce the chance of another fall and another fracture—occult or obvious. (Quality guidance frameworks incorporate these elements alongside surgical care.) ^[12]

The X-ray was normal. Should we still worry?

Yes, if the person cannot walk normally, has point tenderness in the groin or lateral hip, or has pain with gentle rotation. Ask the team whether magnetic resonance imaging (or computed tomography if magnetic resonance imaging is unavailable) will be obtained today to rule out an occult fracture. ^[4]

Which scan is best?

Magnetic resonance imaging is the most sensitive test for occult hip fractures, and a negative magnetic resonance imaging essentially rules it out. Computed tomography is very useful and widely available, but a negative computed tomography may still need magnetic resonance imaging if symptoms strongly suggest a fracture. ^[6]

How fast should surgery happen once a fracture is found?

As a rule, within 24–48 hours if medically possible. Earlier surgery is linked to better survival and fewer complications. ^[9]

Can waiting a few days make the fracture worse?

Yes. Delays increase pain, risk of displacement, bed-related complications, and mortality—one reason why guidelines stress rapid diagnosis and timely surgery. ^[12]

1. Do not dismiss ongoing hip pain and inability to bear weight after a fall just because radiographs are normal. Occult fractures are real and consequential. ^[1]
2. Order magnetic resonance imaging within 24 hours when suspicion remains high; use computed tomography if magnetic resonance imaging is not immediately available, but follow with magnetic resonance imaging if doubt persists. ^[4]
3. Confirm the diagnosis and operate within 24–48 hours when indicated: this saves lives and function. ^[9]

This article is educational and does not replace medical evaluation. If someone has persistent hip pain or cannot walk normally after a fall, seek urgent care and ask about magnetic resonance imaging or computed tomography to rule out an occult hip fracture.