Synopsis
Recognise when normal initial radiographs leave clinically important fracture risk unresolved, choose MRI or CT for the suspected structure, and provide protection and follow-up meanwhile.
- An occult fracture is clinically suspected but not visible or confidently diagnosable on the initial radiographic examination.
- First confirm that the correct region, adequate orthogonal views and any appropriate targeted projection were obtained and reviewed against maximal tenderness.
- NICE advises considering MRI first line after thorough examination for suspected scaphoid fracture rather than assuming normal radiographs exclude it.
Key red flags
An older person unable to bear weight after a fall needs an occult hip-fracture pathway even when adequate hip radiographs are negative.
Persistent anatomical snuffbox or scaphoid-tubercle tenderness can represent a scaphoid fracture with later nonunion or avascular necrosis risk.
Pain out of proportion, worsening swelling or new neurological or perfusion abnormality requires immediate clinical review rather than simply another image.
Children may have radiographically occult physeal, cartilaginous or buckle injury; focal examination findings and developmental anatomy must guide protection.
Groin pain, pain on axial loading or rotation and inability to mobilise after a fall should trigger further imaging despite adequate negative radiographs.
Investigation priorities
Correct missing coverage or projection and demonstrate interval sclerosis, callus or displacement.
Management branches
An adult remains unable to bear weight with suspected hip fracture after adequate normal radiographs.
- Maintain analgesia and safe transfer while treating the hip as fractured until the question is resolved.
- Offer MRI and arrange it within the urgent pathway; if unavailable within 24 hours or contraindicated, consider CT.