Is a computed tomography (CT) scan recommended in the emergency department for an older adult with persistent severe left hip pain, rated 8/10, after a mechanical ground-level fall, with a negative radiograph (x-ray) and possible osteoporosis?

CT is Recommended in the Emergency Department for This Patient

For an adult with severe (8/10) hip pain after a ground-level fall and negative radiographs, CT hip without IV contrast should be obtained immediately in the emergency department to rule out occult fracture, as approximately 24% of such patients harbor radiographically occult hip fractures that require urgent management. 1

Why CT is Critical in This Clinical Scenario

High Probability of Occult Fracture

• 39% of patients with negative hip radiographs but persistent clinical suspicion for fracture actually have surgical hip fractures requiring operative intervention 1, 2
• CT detects occult hip fractures in 24.1% of cases with negative X-rays and changes management in 20% of patients 1
• CT demonstrates 94% sensitivity and 100% specificity for occult hip fractures when radiographs are negative 1

Speed Advantage in the Emergency Department

• CT is faster to obtain than MRI or bone scan, making it the preferred next imaging study when rapid diagnosis is needed to decrease fracture-related morbidity 1
• The American College of Radiology specifically recommends CT hip without IV contrast as the next imaging examination after negative radiographs when there is persistent clinical concern for hip fracture 1
• Delayed diagnosis increases risk of osteonecrosis, prolonged immobility, and secondary displacement 2, 3

Specific Fracture Types CT Will Detect

• Nondisplaced femoral neck fractures are the most common occult fracture pattern in this clinical scenario 2
• Intertrochanteric fractures with radiographically occult extension are frequently missed on plain films 2
• Isolated greater trochanter fractures on X-ray frequently have intertrochanteric extension visible only on CT 2

Clinical Algorithm for This Patient

1. Obtain CT hip without IV contrast immediately in the emergency department given the 8/10 pain severity and high pretest probability of occult fracture 1, 2

2. If CT is negative but clinical suspicion remains high (patient still cannot bear weight, severe pain persists), proceed to MRI hip without IV contrast, as CT has documented false-negatives in approximately 50 cases across meta-analyses 1, 2

3. If both CT and MRI are negative, consider soft tissue injuries including muscle/tendon tears, trochanteric bursitis, or referred pain from lumbar spine pathology 2, 4

MRI as Alternative First-Line Advanced Imaging

• MRI hip without IV contrast approaches 100% sensitivity for fracture detection and is rated as "usually appropriate" (rating 9/9) by the American College of Radiology for suspected hip fracture with negative radiographs 1
• MRI should be chosen over CT if time permits and comprehensive soft tissue evaluation is desired, or if the patient can tolerate the longer scan time 2
• However, in the emergency department setting with severe pain, CT's speed advantage makes it the more practical choice for initial advanced imaging 1

Critical Pitfalls to Avoid

• Never assume a negative X-ray excludes fracture in a trauma patient with severe persistent pain, as up to 39% harbor occult fractures requiring surgical intervention 2
• Do not wait 10-14 days for repeat radiographs in hip fracture cases, as the American College of Radiology specifically states "it is not advisable to wait 10-14 days in most cases" due to high risk of complications 1
• Do not order CT with IV contrast, as there is no evidence supporting its use and it adds unnecessary cost, radiation, and contrast-related risks 1
• Increasing the number of radiographic projections does not decrease the need for CT when clinical suspicion remains high 1

Special Considerations for Possible Osteoporosis

• Ground-level falls in patients with osteoporosis have particularly high risk for occult fractures, as osteoporosis increases bone fragility and fracture susceptibility 5
• The threshold for obtaining CT should be even lower in patients with osteoporosis risk factors (older age, low body weight, prior fractures, glucocorticoid use) 5
• CT's superior ability to detect subtle fractures in osteoporotic bone makes it especially valuable in this population 6, 7