What is the management approach for a patient with a normal pelvic and left hip radiograph, showing no evidence of acute fracture or dislocation, and preserved bone density?

Management of Normal Pelvic and Hip Radiographs with Clinical Suspicion

If the patient has persistent hip pain despite normal radiographs, obtain an MRI without contrast to rule out occult fracture, as up to 10% of proximal femoral fractures are radiographically occult. 1

Clinical Context Assessment

The critical decision point hinges on whether clinical suspicion for fracture remains despite negative imaging:

If Patient Has Persistent Hip Pain or Clinical Concern for Fracture

• MRI of the pelvis and affected hip without IV contrast is the next imaging study of choice 1
• MRI should be obtained when radiographs are negative but clinical suspicion persists, as demonstrated in the AAOS case series where a patient with initially negative radiographs returned with worsening pain and MRI revealed a mildly displaced basicervical femoral neck fracture 1
• At least 90% of proximal femoral fractures are identified on radiographs, but the remaining 10% require advanced imaging 1
• CT without IV contrast is an acceptable alternative when MRI is contraindicated or unavailable, though it is less sensitive than MRI for occult fractures 1

Key Clinical Red Flags Requiring Advanced Imaging

• Pain that worsens with internal and external rotation of the hip 1
• Inability to bear weight despite normal radiographs 1
• Pain that increases over 2-3 days following initial presentation 1
• History of fall or trauma in elderly patients, even low-force mechanisms 1

If Patient Is Asymptomatic or Has Minimal Pain

Conservative Management Approach

• Instruct patient to use crutches and weight-bear as tolerated 1
• Provide explicit return precautions: return immediately if discomfort worsens or fails to improve 1
• Schedule follow-up within 2-3 days for clinical re-evaluation 1

Important Pitfall to Avoid

The AAOS guidelines specifically highlight a case where a patient was sent home after negative radiographs with instructions to return if pain did not abate—the patient returned 2 days later with worsening pain, and MRI revealed a fracture that was initially radiographically occult 1. This underscores that negative radiographs do not exclude fracture when clinical suspicion remains high.

Additional Considerations for Elderly Patients

Even with normal radiographs, elderly patients with hip pain after falls require:

• Comprehensive multidisciplinary assessment including CBC, electrolytes, and ECG 2
• Multifactorial falls risk assessment incorporating gait, balance, lower limb strength, medication review, and cognitive evaluation 2
• Referral to Fracture Liaison Service or Bone Health Clinic for secondary fracture prevention 2
• Evaluation for osteoporosis with consideration of calcium, vitamin D supplementation, and bisphosphonates 2

Imaging Limitations to Remember

• Pelvis and hip radiographs share limitations in sensitivity and specificity, and negative radiographs alone cannot exclude fracture 1
• Plain radiographs are not accurate in detecting fracture fragments within the hip joint 3
• The sensitivity of radiographs depends on fracture location, displacement, and timing of imaging 1