Can You Have a Broken Hip With a Normal X-Ray? Occult Hip Fractures Explained

Written by the LSRI clinical team and medically reviewed by Dr Prashant Sankaye, Consultant MSK Radiologist, on 9 October 2026.

Most broken hips show clearly on an X-ray, but a small number do not. An occult hip fracture is a real break in the top of the thigh bone that the first X-ray misses. It is found later on a more sensitive scan, such as MRI or CT^1,2. An unrecognised fracture cannot be treated, and a fine crack can shift into a more serious break³.

This guide covers who is at risk, which symptoms not to dismiss and what delay can cost. After a fall with severe hip or groin pain, or if you cannot put weight on the leg, go to A&E (the emergency department) or call 999⁴.

What is an occult hip fracture?

An occult hip fracture is a break in the upper thigh bone (the femur) that is present but not visible on the first X-ray². Occult simply means hidden.

Most hip fractures involve the femoral neck, the narrow section just below the ball of the joint, or the bone slightly lower down. A displaced fracture, where the broken ends have moved apart, is usually obvious. A non-displaced fracture, a crack where the bone stays in line, can be invisible on X-ray².

MRI (magnetic resonance imaging) uses a strong magnet and radio waves. It can sometimes detect a small or incomplete fracture that cannot be seen on an X-ray⁵. CT (computed tomography) uses X-rays and a computer to build detailed cross-sectional pictures. The wrist has the same problem: see scaphoid fractures with a normal X-ray.

How often does a normal X-ray miss a hip fracture?

Not often, but often enough to matter. X-rays detect at least 90% of hip fractures. About 3 to 4 in 100 emergency patients having a hip X-ray have an occult fracture¹.

A meta-analysis pools the results of many studies. The figures differ because the groups differ. The lower figure covers everyone with a normal X-ray, and most of them did not have an MRI. The higher figures come from people who still could not stand, or who were sent for advanced imaging^8,13,14.

Put the other way round, about 96 in 100 people with hip pain and a normal X-ray in the emergency study had no hip or pelvic fracture found¹³. Still, severe pain or not walking normally after a fall should not be dismissed because one X-ray looks clear.

Who is most at risk?

Hip fractures are most common in older people and in people with osteoporosis, a condition in which bones become thinner and break more easily⁴. Most follow a low-energy fall in someone whose bones are already weakened⁵.

Hidden fractures are more frequent in people aged 80 or over⁸. A missed diagnosis is more likely in people who are confused or had poor mobility before the fall³. In one hospital review, 7 of 9 patients whose occult fracture was first missed had confusion, against none of 15 diagnosed promptly³.

Younger people can be affected too. A femoral neck stress fracture builds up from repeated loading, mostly in military recruits and endurance athletes. It causes gradual groin pain that eases with rest, and X-rays are often normal¹⁵. See our article on hip stress fractures and hip pain that is not improving.

What does an occult hip fracture feel like?

Usually pain in the groin, hip or upper thigh after a fall, often with difficulty standing. Signs of a broken hip include⁴:

• pain in the hip, groin or upper thigh
• not being able to stand or put weight on the leg
• difficulty moving the hip and leg
• the leg looking shorter, or lying at an odd angle
• swelling or bruising around the hip

Some fractures, usually non-displaced femoral neck fractures, hurt less at first, and a person may still bear weight⁵. Examination alone cannot reliably diagnose or exclude a hip fracture, so imaging is needed¹⁶.

Why can hidden hip fractures be missed?

Mainly because of the limits of X-ray and the way these fractures behave, not because anyone is careless.

• The crack has not moved, so the X-ray can look normal^1,2.
• The person can still walk, so the injury looks less serious⁵.
• Confusion and frailty make assessment harder³.
• MRI is not always possible or quickly available, and CT, used instead, misses a minority of fractures^7,14.

What can delay cost?

An unprotected crack can shift into a worse fracture, and later diagnosis means later surgery. In older people, longer waits for surgery are linked with more complications and deaths.

A crack can become a displaced fracture

In one review of 24 occult hip fractures, 9 were initially missed. Eight of the 9 were intracapsular fractures (inside the capsule that surrounds the hip joint), and 6 of those 8 later shifted out of position. Three of the 9 patients died within a year³. This was a small study, and the missed patients were also frailer, so not every death can be blamed on the delay.

Displacement changes the operation. For displaced femoral neck fractures, replacing part or all of the hip joint is recommended over fixing it with screws¹⁷. If a femoral neck stress fracture is left untreated, it can progress to a complete, displaced break. This can be followed by non-union (failure to heal) or by osteonecrosis, where part of the ball of the hip loses its blood supply and dies¹⁵.

Waiting longer for surgery is linked with worse outcomes

Hip fracture is serious: in one large study, 7.0% of adults died within 30 days of surgery¹⁰. Most evidence on delay comes from people already diagnosed and waiting for surgery, not occult fractures specifically. It still shows why time matters.

• In 35 studies (191,873 patients), earlier surgery was linked with lower odds of death (odds ratio 0.74). Most studies used a cut-off between 24 and 48 hours⁹.
• Earlier surgery was also linked with fewer pressure sores^9,18 and, in unadjusted data, less pneumonia¹⁸.
• In 42,230 adults at 72 hospitals, complications rose once the wait passed 24 hours. In matched groups, 30-day mortality was 6.5% after longer waits and 5.8% with earlier surgery¹⁰.
• A review of 28 prospective studies linked surgery within 48 hours with a 20% lower risk of dying within 12 months. Within versus after 24 hours made no significant difference. The authors rated the certainty of this evidence as low¹⁹.

The honest message from the HIP ATTACK trial

These studies are observational: they show a link, not proof that delay causes harm. The HIP ATTACK trial tested it directly in 2,970 patients in 17 countries. Median time from diagnosis to surgery was 6 hours with accelerated surgery and 24 hours with standard care. Deaths at 90 days (9% versus 10%) and major complications (22% in both) did not differ significantly¹¹.

The evidence therefore points towards surgery within a day or two, and avoiding delays of days, the kind a missed fracture can cause. The American Academy of Orthopaedic Surgeons (AAOS) 2021 guideline says surgery within 24 to 48 hours of admission may be associated with better outcomes¹⁷. In England, the hip fracture Best Practice Tariff, a national hospital payment standard, includes surgery within 36 hours. The clock starts at arrival in the emergency department, or at diagnosis for patients already in hospital²⁰.

How is an occult hip fracture diagnosed?

An X-ray comes first. If it is normal or uncertain but a fracture is still suspected, MRI is the preferred next test. CT is the alternative when MRI is not possible^6,7,16.

An earlier AAOS guideline (summarised in 2015) found moderate evidence for MRI as “the advanced imaging of choice” here⁶. The 2021 AAOS update covers treatment and makes no recommendation on imaging¹⁷. The American College of Radiology’s 2024 criteria rate MRI and CT both usually appropriate, and a bone scan usually not appropriate¹⁶.

Sensitivity is the share of real fractures a test detects. MRI also shows other injuries: in one study, soft-tissue injuries in 39% of patients².

When hip pain is probably not an occult fracture

Occult hip fractures are an injury problem. Hip pain that has built up over weeks without a fall has many possible causes, and follows a different, non-emergency route¹².

Common causes include osteoarthritis, tendon problems and bursitis. See a GP (family doctor) if pain has not improved after two weeks of home treatment. Get urgent advice from a GP or NHS 111 for sudden severe hip pain without a fall, or a hot, swollen hip¹².

A scan is not needed for every sore hip, but some causes without a fall do need proper imaging:

• stress fractures of the femoral neck in endurance athletes and military recruits¹⁵
• avascular necrosis of the hip, when the ball of the hip loses its blood supply
• sacral insufficiency fractures, cracks in the base of the spine in people with osteoporosis
• hip osteoarthritis, when the diagnosis is uncertain

What to do after a fall with hip or groin pain

1. Do not try to walk it off. If you cannot get up, stand or put weight on the leg, call 999 for an ambulance⁴.
2. Go to A&E with severe pain after a fall, even if you can walk. Some people with a hip fracture can still bear weight^5,12.
3. Do not drive yourself. Ask someone to take you or call 999, and bring your medicines⁴.
4. Say if you are still struggling after a normal X-ray. If you cannot walk normally or pain is severe, tell the team. MRI or CT may be needed^6,16.
5. Watch older relatives closely. Missed fractures are more likely with confusion or poor mobility, so a new limp or ongoing hip pain after a fall deserves review³.
6. Call 999 for warning signs. These include being unable to bear weight, a leg that looks shorter or lies at an odd angle, or tingling or numbness^4,12.

What happens once a hip fracture is diagnosed?

Most hip fractures are treated with an operation, then early mobilisation, rehabilitation, and a check of bone health and falls risk⁴.

• Surgery usually happens on the day of arrival or the next day. The bone is fixed with screws, nails or plates, or the joint is partly or fully replaced⁴.
• Getting moving. Most people get out of bed and start physiotherapy the day after surgery⁵. Interdisciplinary team care is strongly recommended¹⁷.
• Bone health and falls. Osteoporosis should be checked and treated⁶. English standards include falls and bone health assessments²⁰, and a fracture liaison service may help prevent further fractures⁴.
• Recovery takes weeks or months, and some people do not regain their previous strength⁴.

What LSRI can and cannot do

LSRI is not an emergency service, and we do not provide emergency assessment, emergency CT or surgery. After a fall with severe hip or groin pain, or if you cannot put weight on your leg, go to A&E or call 999 now. Please do not wait for, or book, a private scan.

We can help later, when hip or groin pain persists after normal initial tests and the cause is unclear. An MRI scan reported by a Consultant MSK Radiologist can look for stress fractures, avascular necrosis, labral tears and tendon problems. MRI starts from £375 per body part, including the scan, a specialist report and access to your images, or from £425 with a consultation. Reports are usually ready within 24 hours.

Unsure about a hip MRI report from elsewhere? See our second opinion page. For the wider picture, read why early imaging matters in musculoskeletal injuries. Our clinics are at Harley Street (W1G 9QJ) and Harrow (HA2 7SJ). Call 0203 633 5040.

Reading this from outside the UK?

The medical facts here apply everywhere. Emergency numbers differ: 999 or 112 in the UK, 112 in the European Union, 911 in the US and Canada, 000 in Australia. The 36-hour standard is English and the AAOS guidance American, but both point the same way.

Frequently asked questions

Can you walk with a broken hip?

Sometimes. Not being able to stand or put weight on the leg is a typical sign of a broken hip⁴. With some fractures, usually non-displaced femoral neck fractures, a person can still move the leg and bear weight, although it hurts⁵. Being able to walk after a fall does not rule out a fracture.

Is MRI or CT better for a suspected hidden hip fracture?

MRI is generally the preferred test^6,8. CT is faster and finds most fractures, with a pooled sensitivity of 94% in one meta-analysis⁷, although another found 79%⁸. In one study of 67 people, CT missed 2 of the 15 fractures seen on MRI¹⁴. Because CT misses some, MRI is advised if concern continues after a normal CT⁷.

How soon should a broken hip be operated on?

The AAOS guideline says surgery within 24 to 48 hours of admission may be associated with better outcomes¹⁷, and the English standard is 36 hours²⁰. Operating within 6 hours rather than about 24 did not significantly reduce deaths or complications in a large trial¹¹.

Can a hairline hip fracture heal without surgery?

Sometimes, but surgery is the usual treatment⁴. For stable, non-displaced femoral neck fractures, the AAOS guideline lists partial replacement, fixation or non-operative care as options that may be considered, with limited supporting evidence¹⁷. The risk is that an unprotected crack shifts: in one study, 6 of 8 missed intracapsular fractures later displaced³. The decision belongs with the orthopaedic team after proper imaging.

I have had hip pain for weeks without a fall. Could it be a fracture?

There are many possible causes, such as osteoarthritis, tendon problems or bursitis¹². Stress fractures of the femoral neck are described as relatively rare, but they can develop without a fall in endurance athletes and military recruits and may not show on X-ray¹⁵. See a GP if the pain is not improving after two weeks, and get urgent advice for sudden severe pain¹².

References

1. Cannon J, Silvestri S, Munro M. Imaging choices in occult hip fracture. J Emerg Med 2009;37(2):144-152. doi:10.1016/j.jemermed.2007.12.039
2. Verbeeten KM, Hermann KL, Hasselqvist M, Lausten GS, Joergensen P, Jensen CM, et al. The advantages of MRI in the detection of occult hip fractures. Eur Radiol 2005;15(1):165-169. doi:10.1007/s00330-004-2421-2
3. Hossain M, Akbar SA, Andrew JG. Misdiagnosis of occult hip fracture is more likely in patients with poor mobility and cognitive impairment. Acta Orthop Belg 2010;76(3):341-346. PMID: 20698455
4. NHS. Broken hip. Page last reviewed 29 July 2026. nhs.uk
5. American Academy of Orthopaedic Surgeons. OrthoInfo: Hip fractures. Accessed 8 October 2026. orthoinfo.org
6. Brox WT, Roberts KC, Taksali S, Wright DG, Wixted JJ, Tubb CC, et al. The American Academy of Orthopaedic Surgeons evidence-based guideline on management of hip fractures in the elderly. J Bone Joint Surg Am 2015;97(14):1196-1199. doi:10.2106/JBJS.O.00229
7. Kellock TT, Khurana B, Mandell JC. Diagnostic performance of CT for occult proximal femoral fractures: a systematic review and meta-analysis. AJR Am J Roentgenol 2019;213(6):1324-1330. doi:10.2214/AJR.19.21510
8. Haj-Mirzaian A, Eng J, Khorasani R, Raja AS, Levin AS, Smith SE, et al. Use of advanced imaging for radiographically occult hip fracture in elderly patients: a systematic review and meta-analysis. Radiology 2020;296(3):521-531. doi:10.1148/radiol.2020192167
9. Moja L, Piatti A, Pecoraro V, Ricci C, Virgili G, Salanti G, et al. Timing matters in hip fracture surgery: patients operated within 48 hours have better outcomes. A meta-analysis and meta-regression of over 190,000 patients. PLoS One 2012;7(10):e46175. doi:10.1371/journal.pone.0046175
10. Pincus D, Ravi B, Wasserstein D, Huang A, Paterson JM, Nathens AB, et al. Association between wait time and 30-day mortality in adults undergoing hip fracture surgery. JAMA 2017;318(20):1994-2003. doi:10.1001/jama.2017.17606
11. HIP ATTACK Investigators. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial. Lancet 2020;395(10225):698-708. doi:10.1016/S0140-6736(20)30058-1
12. NHS. Hip pain in adults. Page last reviewed 20 November 2025. nhs.uk
13. Dominguez S, Liu P, Roberts C, Mandell M, Richman PB. Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial standard radiographs: a study of emergency department patients. Acad Emerg Med 2005;12(4):366-369. doi:10.1197/j.aem.2004.10.024
14. Haubro M, Stougaard C, Torfing T, Overgaard S. Sensitivity and specificity of CT- and MRI-scanning in evaluation of occult fracture of the proximal femur. Injury 2015;46(8):1557-1561. doi:10.1016/j.injury.2015.05.006
15. Bernstein EM, Kelsey TJ, Cochran GK, Deafenbaugh BK, Kuhn KM. Femoral neck stress fractures: an updated review. J Am Acad Orthop Surg 2022;30(7):302-311. doi:10.5435/JAAOS-D-21-00398
16. Expert Panel on Musculoskeletal Imaging; Bartolotta RJ, Ha AS, Bateni CP, Chen KC, Dvorzhinskiy A, Flug J, et al. ACR Appropriateness Criteria Acute Hip Pain: 2024 update. J Am Coll Radiol 2025;22(5S):S3-S13. doi:10.1016/j.jacr.2025.02.039
17. American Academy of Orthopaedic Surgeons. Management of hip fractures in older adults: evidence-based clinical practice guideline. Adopted 3 December 2021. aaos.org
18. Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, DeBeer J, et al. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ 2010;182(15):1609-1616. doi:10.1503/cmaj.092220
19. Klestil T, Röder C, Stotter C, Winkler B, Nehrer S, Lutz M, et al. Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis. Sci Rep 2018;8(1):13933. doi:10.1038/s41598-018-32098-7
20. NHS England. 2022/23 National Tariff Payment System. Annex C: Guidance on best practice tariffs (fragility hip and femur fracture). 2022. england.nhs.uk
21. Quinn SF, McCarthy JL. Prospective evaluation of patients with suspected hip fracture and indeterminate radiographs: use of T1-weighted MR images. Radiology 1993;187(2):469-471. doi:10.1148/radiology.187.2.8475292
22. Rizzo PF, Gould ES, Lyden JP, Asnis SE. Diagnosis of occult fractures about the hip. Magnetic resonance imaging compared with bone-scanning. J Bone Joint Surg Am 1993;75(3):395-401. doi:10.2106/00004623-199303000-00011

Book an appointment

Call 0203 633 5040 or book online. Clinics at Harley Street (W1G 9QJ) and Harrow (HA2 7SJ). If you have emergency symptoms, go to A&E or call 999 instead.