Objective To systematically review the imaging methods for identifying occult fractures in patients with osteoporosis, to assess the diagnostic efficacy of different imaging techniques, and to provide a guiding strategy for imaging examinations in orthopedic clinical practice. Methods PubMed, CNKI, Wanfang Database and other databases were searched to collect literature related to occult fractures published from January 2020 to December 2024, and these literature were comprehensively analyzed in terms of the principles of imaging technology, diagnostic efficacy, and clinical application. Results Among the conventional imaging methods, plain radiographs (X-ray) have limited sensitivity in the diagnosis of occult fractures, while computed tomography (CT) examination has better detection capability. Magnetic resonance imaging (MRI) has the best performance in the diagnosis of occult fractures, and short tau inversion recovery (STIR) and fat-suppression sequence (FSIR) are more sensitive in detecting early bone marrow edema. Nuclide bone scans have high diagnostic sensitivity, and single-photon emission computed tomography (SPECT)/CT image fusion can further improve diagnostic specificity. Quantitative CT and high-resolution peripheral quantitative computed tomography (HR-pQCT) techniques are capable of assessing bone microstructure and bone strength. Deep learning (DL)-based artificial intelligence (AI) has demonstrated excellent diagnostic performance in fracture identification. Multimodal imaging-based combined diagnosis can greatly improve diagnostic accuracy. Conclusion The imaging diagnosis of occult fractures should adopt a stratification strategy, and MRI is the most sensitive examination method. Multimodal imaging-based combined diagnosis and AI-assisted diagnosis represent the future development trend. It is recommended to establish a standardized examination process and strengthen the clinical translation and application of new technologies.