What is the best diagnostic approach for an elderly patient with a possible hip fracture, considering potential underlying conditions such as osteoporosis or dementia?

Diagnostic Imaging for Suspected Hip Fracture in Elderly Patients

Plain radiographs (AP with 15° internal rotation and cross-table lateral) are the mandatory first-line imaging study for all elderly patients with suspected hip fracture, but if clinical suspicion remains high despite negative radiographs, proceed immediately to MRI without IV contrast as the next step—not CT. 1

Initial Imaging Approach

• Start with standard hip radiographs including anteroposterior view with 15 degrees of internal rotation and cross-table lateral view of the affected hip 1
• Radiographs rapidly identify most fractures and are well-tolerated, making them appropriate for initial evaluation 1
• When fractures are clearly demonstrated on radiographs, no additional imaging is typically needed for treatment planning 1

When Radiographs Are Negative But Clinical Suspicion Remains High

The 2025 ACR Appropriateness Criteria explicitly state there is no evidence to support CT without IV contrast as the initial imaging study for acute traumatic hip pain. 1 This represents a critical update from older practice patterns.

MRI is the Preferred Advanced Imaging Modality

• MRI without IV contrast is the appropriate next step when radiographs are negative or equivocal but clinical suspicion persists 1, 2, 3
• MRI has superior accuracy compared to CT for detecting occult hip fractures 4
• In a direct comparison study, CT misdiagnosed 4 of 6 patients (67% error rate), while MRI was 100% accurate in all cases 4
• The frequency of radiographically occult surgical hip fractures requiring surgery is 39% in patients with negative radiographs and 92% in patients with isolated greater trochanter fractures on radiographs 5

CT Has Limited Role in This Clinical Scenario

• CT should not be used as the initial advanced imaging modality for suspected hip fracture 1
• While older studies suggested CT had 94% sensitivity, direct comparison shows it is inferior to MRI and leads to misdiagnosis 2, 4
• CT may miss subtle fractures that MRI readily detects, potentially delaying appropriate surgical management 4

High-Risk Populations Requiring Lower Threshold for Advanced Imaging

• Patients aged ≥80 years have 44% rate of occult fractures despite negative radiographs 5
• Patients with equivocal radiographic reports have 58% rate of occult fractures 5
• Patients with dementia are at increased fracture risk and may have atypical presentations 6
• Patients with prior fragility fractures have significantly elevated risk of subsequent fractures 1

Critical Management Principles

Timing and Multidisciplinary Care

• Surgery must occur within 24-48 hours of admission to significantly reduce mortality and complications 1, 2, 3
• Delays beyond 12 hours increase 30-day mortality risk 1
• Orthogeriatric comanagement on a dedicated ward (Level IA evidence, Grade A recommendation) improves functional outcomes, reduces hospital length of stay, and lowers 1-year mortality 1, 7

Immediate Preoperative Management

• Provide adequate pain relief using nerve blocks, which are more effective than systemic analgesia alone 1, 2
• Ensure appropriate fluid management to correct hypovolemia 1, 2
• Perform comprehensive assessment for malnutrition, electrolyte disturbances, anemia, cardiac/pulmonary disease, and cognitive function 1, 3, 7
• Obtain complete blood count, comprehensive metabolic panel, ECG, and coagulation studies 2, 3, 7

Common Pitfalls to Avoid

• Never rely on preserved range of motion or ability to bear weight to exclude fracture—patients with minimally displaced fractures can maintain function initially 2, 7
• Do not order CT as the advanced imaging study when radiographs are negative—this represents outdated practice that delays diagnosis 1, 4
• Do not delay advanced imaging in high-risk elderly patients with negative radiographs, as 39-92% will have occult fractures requiring surgery 5
• Avoid complete bed rest even when imaging is negative, as immobility increases complications including pneumonia, pressure ulcers, and deconditioning 2

Secondary Fracture Prevention

• All patients ≥50 years with hip fracture should be systematically evaluated for risk of subsequent fractures (Level IA evidence, Grade A recommendation) 1
• Refer to Fracture Liaison Service for comprehensive osteoporosis evaluation 2, 3, 7
• Initiate pharmacological treatment with bisphosphonates to reduce risk of subsequent fractures (Level IB evidence, Grade A recommendation) 1, 2
• Ensure adequate calcium and vitamin D supplementation 1, 2, 3
• Implement multifactorial fall prevention strategies including balance training 1, 2, 3