Use of Multislice CT for Investigation of Occult Geriatric Hip Fractures and Impact on Timing of Surgery

Introduction: The National Institute of Health and Clinical Excellence guidelines in the United Kingdom recommend magnetic resonance imaging (MRI) as the first-line investigation for radiographically occult hip fractures, if available within 24 hours. In our department, however, multislice computerized tomography (MSCT) is instead used as a first-line investigation due to significant delays associated with obtaining MRI. Our aim was to determine the validity and practicality of MSCT for diagnosis of occult hip fractures and its impact on timing of surgery. Materials and Methods: We retrospectively analyzed medical records and imaging for consecutive patients who underwent MSCT to investigate occult hip fractures between January 2014 and October 2016. We reviewed subsequent imaging and reattendances for patients with negative MSCT to exclude initially missed fractures. Results: Two hundred six patients underwent MSCT to investigate occult hip fracture during the study period. Hip fractures were identified in 59 patients, comprising 35 (59.3%) subcapital, 12 (20.0%) intertrochanteric, 8 (13.6%) transcervical, and 4 (6.8%) basicervical fractures. One missed hip fracture was identified: a patient with a negative MSCT was further investigated with MRI that demonstrated acute subcapital hip fracture. Multislice computerized tomography was obtained within 24 hours of initial radiograph in 145 (70.4%) patients. A total of 44.5% of occult hip fractures had surgery within the nationally recommended 36 hours of admission (hospital average for all hip fractures was 76.4% over the same period). Discussion and Conclusions: Multislice computerized tomography is a pragmatic approach to investigate the majority of occult hip fractures in a timely manner and minimize associated delay to surgery. However it cannot completely exclude the diagnosis, especially in abnormal anatomy. The lack of a true gold standard comparison (ie, MRI) means a true sensitivity and specificity cannot be calculated, although can be cautiously estimated by lack of subsequent reattendance or investigation. Further prospective randomized CT versus MRI trials are required.

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BET 2: CT versus MRI for occult hip fractures

Emergency Medicine Journal ◽

10.1136/emermed-2018-208093.3 ◽

2018 ◽

Vol 35 (10) ◽

pp. 645-647 ◽

Cited By ~ 1

Author(s):

Bernard A Foex ◽

Anna Russell

Keyword(s):

Hip Fracture ◽

Ct Scan ◽

Hip Fractures ◽

Clinical Suspicion ◽

First Line ◽

Bottom Line ◽

X Ray ◽

Occult Hip Fracture ◽

Study Type ◽

Occult Hip Fractures

A short-cut review was carried out to establish whether CT or MRI is better at detecting an occult hip fracture. Six studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that CT is a valid first-line investigation for a suspected plain X-ray occult hip fracture. If clinical suspicion remains after a negative CT scan, then MRI should be used.

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Bilateral occult hip fracture

CJEM ◽

10.2310/8000.2012.110631 ◽

2012 ◽

Vol 14 (06) ◽

pp. 372-377 ◽

Cited By ~ 3

Author(s):

Willis B. Grad ◽

Nicholas M. Desy

Keyword(s):

Emergency Department ◽

Hip Fracture ◽

Hip Fractures ◽

Plain Radiographs ◽

Diagnostic Studies ◽

Acute Injuries ◽

Occult Hip Fracture ◽

Occult Hip Fractures

ABSTRACTOne of the most common acute injuries seen in the emergency department is the hip fracture. This injury is usually diagnosed by plain radiographs, however these fractures are sometimes not obviously apparent. Occult hip fractures present a pitfall for emergency department physicians. We present a case of a patient who sustained bilateral occult hip fractures. We review the epidemiology of the condition, examine what diagnostic studies are available that may help the physician avoid missing the occult hip fracture and what the literature tells us about the utility of each of these modalities. The prognosis of the occult hip fracture along with options for treatment is also discussed.

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LO12: The utility of femoral nerve blocks in the emergency department; a national survey of practice

CJEM ◽

10.1017/cem.2017.74 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S31

Author(s):

J. Ringaert ◽

J. Broughton ◽

M. Pauls ◽

I. Laxdal ◽

N. Ashmead

Keyword(s):

Emergency Department ◽

Hip Fracture ◽

Hip Fractures ◽

Femoral Nerve ◽

Comfort Level ◽

Emergency Physicians ◽

First Line ◽

Nerve Blocks ◽

Canadian Association ◽

The University

Introduction: Approximately 30,000 hip fractures occur annually in Canada, and the incidence will increase with an aging population. Pain control remains a challenge with these patients, as many are elderly and prone to delirium. Regional anesthesia has shown to be very effective with minimal risks, but it is not clear how often emergency physicians are using this technique to provide analgesia for patients with proximal hip fractures. This is the first Canada-wide survey to evaluate the use of regional anaesthesia in the emergency department for hip fractures. It also evaluates physician comfort level with performing these blocks, perceived educational needs in this area, and barriers to performing nerve blocks. Methods: A 13-question survey was sent to 1041 members of the Canadian Association of Emergency Physicians via email in January and February of 2016. Data was collected and analysed using an online collection program called “Survey Monkey”. Ethics approval was obtained through the University of Manitoba Research Ethics Board. Results: 272 Emergency physicians and residents took part in the survey. The majority of respondents (75.9%) choose intravenous opioids as their first line of analgesia and only 7.6% use peripheral nerve blocks (PNB) as their first line choice for analgesia in hip fracture. In response to practitioner comfort with PNBs for hip fractures, most were not at all confident (45.0%) in their ability and many respondents have never performed a nerve block for a hip fracture (53.9%). The most commonly identified barriers to performing PNBs include lack of training, the time to perform the procedure and a lack of confidence. A larger percentage of respondents (34.2%), identified having had no training and no knowledge of how to perform PNBs for hip fractures. Conclusion: The vast majority of Canadian emergency physicians who took part in this survey do not utilize PNBs as a method of pain management for hip fractures. Over half have never performed one of these procedures and many have never received training in how to do so. Future efforts should focus on improving access to education, disseminating information regarding the effectiveness of PNB, and addressing logistical barriers in the ED.

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Important perioperative factors, guidelines and outcomes in the management of hip fracture

Journal of Perioperative Practice ◽

10.1177/1750458920915656 ◽

2020 ◽

pp. 175045892091565

Author(s):

Harry Kyriacou ◽

Wasim S Khan

Keyword(s):

Hip Fracture ◽

Postoperative Complications ◽

Psychosocial Factors ◽

Hip Fractures ◽

The Elderly ◽

Timing Of Surgery ◽

Significant Morbidity ◽

Fracture Management ◽

Fracture Outcome ◽

Type Of Anaesthesia

Hip fractures are common injuries in the elderly and are associated with significant morbidity and mortality. There are multiple perioperative factors that must be considered when managing these patients. These include analgesia, timing of surgery, choice of operation, type of anaesthesia, postoperative complications and comorbidities. Guidelines from The National Institute for Health and Care Excellence and the National Hip Fracture Database have been updated to reflect many of the above, but the importance of psychosocial factors is still emerging. This article focuses on the evidence for the key perioperative factors in hip fracture management and the tools available to predict hip fracture outcome.

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Investigation of Occult Hip Fractures: The Use of CT and MRI

The Scientific World JOURNAL ◽

10.1155/2013/830319 ◽

2013 ◽

Vol 2013 ◽

pp. 1-4 ◽

Cited By ~ 34

Author(s):

S. K. Gill ◽

J. Smith ◽

R. Fox ◽

T. J. S. Chesser

Keyword(s):

Hip Fracture ◽

Multislice Ct ◽

Clinical Suspicion ◽

Fractured Neck Of Femur ◽

Neck Of Femur ◽

Femur Fractures ◽

Occult Hip Fracture ◽

Magnetic Resonance Imaging Mri ◽

Current Guidelines ◽

Ct And Mri

Aim. At present there is no data looking at modern multislice computerised tomography (CT) in the investigation of occult hip fracture. The aim of this study was to retrospectively compare the reports of patients sent for magnetic resonance imaging (MRI) or CT with negative radiographs and a clinical suspicion of a fractured neck of femur.Methods. All patients presenting to the hospital with a clinical suspicion of a hip fracture but initial negative radiographs over a three-year period were included. Patients were either investigated with an MRI scan or CT scan. The presence of a fracture, the requirement for surgery, and any further requirement for imaging were recorded.Results. Over three years 92 patients were included of which 61 were referred for a CT and 31 for an MRI. Thirty-four patients were found to have a fracture. Of these, MRI picked up a fracture in 36% and CT in 38% of referrals.Discussion. Up to 10% of proximal femur fractures may be missed on initial radiographs. Current guidelines state patients should be offered MRI if hip fracture is suspected despite negative hip radiographs. Our findings show that modern multislice CT may be comparable with MRI for detecting occult fracture.

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The use of computed tomography in identifying radiologically occult hip fractures in the elderly

Annals of The Royal College of Surgeons of England ◽

10.1308/003588414x13824511650533 ◽

2014 ◽

Vol 96 (3) ◽

pp. 234-237 ◽

Cited By ~ 20

Author(s):

S Heikal ◽

P Riou ◽

L Jones

Keyword(s):

Computed Tomography ◽

Hip Fractures ◽

Historical Review ◽

The Elderly ◽

Acetabular Fractures ◽

Fractured Neck Of Femur ◽

Neck Of Femur ◽

X Ray ◽

Magnetic Resonance Imaging Mri ◽

Occult Hip Fractures

Introduction Fractured neck of femur (NOF) is a cause of significant morbidity and mortality. Approximately 4% of patients with an initial normal hip x-ray in the emergency department (ED) will in fact have an occult fracture. In cases where there is ongoing clinical suspicion of NOF fracture despite a normal hip x-ray, alternative imaging should be used. Although available evidence supports the use of magnetic resonance imaging (MRI) for this, it is often not readily accessible from the ED. In our department, it is common practice to request computed tomography (CT). Methods A historical review was undertaken of all patients who presented between October 2007 and January 2011 who had CT requested by ED staff. Patients included in the study were those who presented following low impact trauma in whom fractured NOF was suspected despite a normal x-ray. Results Of the 65 included patients, fractures (pelvic and hip) were identified in 38 patients on CT. Fractured NOFs were found in 13 patients. Acetabular fractures were found in nine patients, five of whom required further orthopaedic management. One patient went on to have MRI to confirm the diagnosis of an impacted NOF fracture, suspected both on x-ray and CT. Further review was undertaken of the medical notes of discharged patients to identify any who reattended or required further imaging. No such cases were found. Conclusions This review has shown the use of CT to be a practical approach to improving the care of patients with occult hip fractures.

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Hip fracture litigation: A 10-year review of NHS Litigation Authority data and the effect of national guidelines

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2016.0277 ◽

2017 ◽

Vol 99 (1) ◽

pp. 17-21 ◽

Cited By ~ 2

Author(s):

R Fanous ◽

S Sabharwal ◽

A Altaie ◽

CM Gupte ◽

P Reilly

Keyword(s):

Hip Fracture ◽

Hip Fractures ◽

Best Practice ◽

Clinical Excellence ◽

Freedom Of Information ◽

National Guidelines ◽

Delay In Diagnosis ◽

Significant Difference ◽

Before And After ◽

The Uk

We present a review evaluating all litigation claims relating to hip fractures made in a 10-year period between 2005 and 2015. Data was obtained from the NHS Litigation Authority through a freedom of information request. All claims relating to hip fractures were reviewed. During the period analysed, 216 claims were made, of which 148 were successful (69%). The total cost of settling these claims was in excess of £5 million. The introduction of a best-practice tariff by the Department of Health in 2010 was designed to improve the quality of care for hip fracture patients. This was followed by guidance from the National Institute for Health and Clinical Excellence in 2011 and the British Orthopaedic Association in 2012. We analysed claims submitted before and after these guidelines were introduced and no significant difference in the number of claims was noted. The most common cause for litigation was a delay in diagnosis, which accounted for 86 claims in total (40%). Despite the presence of these guidelines and targets, there has not been a significant reduction in the number of claims or an improvement in diagnostic accuracy. This may be due to an increasing level of litigation in the UK but we must also question whether we are indeed providing best-practice care to our hip fracture patients and whether these guidelines need further review.

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The use of MRI and CT in Imaging Occult Hip Fractures

ARS Medica Tomitana ◽

10.1515/arsm-2015-0007 ◽

2014 ◽

Vol 20 (4) ◽

pp. 207-210

Author(s):

B. Obadă ◽

Al. O. Șerban ◽

V. Botnaru ◽

Al. Valcu

Keyword(s):

Hip Fracture ◽

Hip Fractures ◽

Inclusion Criteria ◽

Daily Lives ◽

Fracture Characterization ◽

Orthopedic Injury ◽

Bone Edema ◽

Occult Hip Fracture ◽

Displaced Fracture ◽

Occult Hip Fractures

Abstract Diagnosis of hip fractures is particularly important due to the high dependence on the integrity of this structure for people to function in their daily lives. Left unrecognized, patients face increasing morbidity and mortality as time from the original injury lengthens. A delay of just 2 days in surgical treatment for an acute hip fracture doubles mortality. In addition, an unrecognized non-displaced fracture may displace, requiring surgery of much higher risk. This may be part of the reason that the most frequent lawsuit against Emergency Physicians is for missed orthopedic injury. We reviewed the use of MRI and CT for occult hip fractures (OHF) detection at a major urban trauma unit. Our study is a retrospective review. Inclusion criteria: all patients presenting to the Emergency Clinical Hospital of Constanta with a suspected, posttraumatic, occult hip fracture, over a 5 years period were included. All patients had negative initial radiographs and underwent further imaging with either CT or MRI. A total of 185 cases meeting the inclusion criteria were identified. 72 occult hip fractures were detected with both imaging modalities. Although MRI certainly enables greater image detail, in our experience both modalities are able to provide satisfactory fracture characterization. The choice of imaging should be determined by availability and indication. MRI provides superior imaging of soft tissue but is less sensitive for degenerative changes in presence of bone edema.

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HIP FRACTURES IN 5 YEARS AT HUE UNIVERSITY HOSPITAL

Journal of Medicine and Pharmacy ◽

10.34071/jmp.2013.6.8 ◽

2014 ◽

pp. 47-50

Author(s):

Duy Binh Ho ◽

Nghi Thanh Nhan Le ◽

Maasalu Katre ◽

Koks Sulev ◽

Märtson Aare

Keyword(s):

Hip Fracture ◽

Femoral Neck ◽

Hip Fractures ◽

Age Groups ◽

Femoral Fractures ◽

Femoral Neck Fractures ◽

University Hospital ◽

High Risk Population ◽

Intertrochanteric Fractures ◽

Significant Difference

Aim: This study aimed to review the clinical findings and surgical intervention of the hip fracture at the Hue University Hospital in Vietnam. Methods:The data of proximal femoral fractures was collected retrospectively. All patients, in a period of 5 years, from Jan 2008 to December 2012, suffered either from intertrochanteric or femoral neck fractures. The numbers of patients were gathered separately for each year, by age groups (under 40, 40-49, 50-59, 60-69, 70-79, older) and by sex. We analyzed what kind of treatment options were used for the hip fracture. Results:Of 224 patients (93 men and 131 women) studied, 71% patients are over 70 years old, 103 women and 56 men (p<0.05). For patients under 40 years, there were 1 woman and 11 men (p<0.05). There were 88 intertrochanteric and 136 femoral neck fractures. There was no significant difference in the two fractures between men and women. The numbers of hip fracture increased by each year, 29/224 cases in 2010, 63/224 cases in 2011, 76/224 cases in 2012. Treatment of 88 intertrochanteric fractures: 49 cases (55.7%) of dynamic hip screw (DHS), 14 cases of hemiarthroplasty (15.9%), 2 cases of total hip replacement (2.3%). Treatment of 136 femoral neck fractures: 48 cases of total replacement (35.3%), 43 cases of hemiarthroplasty (31.6%), 15 cases of screwing (11%). In cases of 40 patients (17.9%) hip fracture was managed conservatively, 23 were femoral neck fractures and 17 were intertrochanteric fractures. Conclusions: Hip fracture is growing challenge in Hue medical university hospital. The conservative approach is still high in people who could not be operable due to severe medical conditions as well as for patients with economic difficulties. Over 70% of the hip fractures in people 70+ are caused by osteoporosis. The number of hip fracture is increasing in the following years, most likely due to the increase in the prevalence of osteoporosis. Early detection and prevention of osteoporosis should be addressed, particularly in high risk population. More aggressive surgical approach should be implemented in order to improve the quality of life in patients with hip fractures. Key words:Hip fracture.

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The effects of information platform-based nursing on preventing venous thromboembolism (VTE) in patients with hip fractures (Preprint)

10.2196/preprints.20947 ◽

2020 ◽

Author(s):

Yuan Gao ◽

Xiaojie Fu ◽

Mingxing Lei ◽

Pengbin Yin ◽

Qingmei Wang ◽

...

Keyword(s):

Hip Fracture ◽

Hip Fractures ◽

Subgroup Analysis ◽

Nursing Intervention ◽

Control Group ◽

Study Group ◽

Drug Compliance ◽

Information Platform ◽

The Difference ◽

Length Of Hospitalization

BACKGROUND Mobile apps are becoming increasingly relevant to health care. Apps have been used to improve symptoms, quality of life, and adherence for oral drugs in patients with cancers, pregnancy, or chronic diseases, and the results were satisfying . OBJECTIVE This study aims to develop an information platform with the help of a mobile app and then evaluate whether information platform-based nursing can improve patient’s drug compliance and reduce the incidence of VTE in patients with hip fractures. METHODS We retrospectively analyzed hip fracture patients performed with traditional prevention and intervention of VTE (control group) between January 2008 and November 2012, and prospectively analyzed hip fracture patients conducted with nursing intervention based on the information platform (study group) between January 2016 and September 2017. The information platform can be divided into medical and nursing care end and the patient’s end. Based on the information platform, we could implement risk assessments, monitoring management and early warnings, preventions and treatments, health educations, follow-up and other aspects of nursing interventions for patients. We compared basic characteristics, outcomes including drug compliance, VTE occurrence, and mean length of hospitalization between the two groups. Besides, a subgroup analysis was performed in the study group according to different drug compliances. RESULTS Regarding baseline data, patients in the study group had more morbidities than those in the control group (P<0.05). The difference of drug compliance between the two groups was statistically significant (P<0.001): 64.7% of the patients in the control group had poor drug compliance and only 6.1% patients had poor drug compliance in the study group. In terms of VTE, 126 patients (10.7%) in the control group had VTE, while only 35 patients (7.1%) in the study group had VTE, and the difference was statistically significant (P=0.024). Moreover, the average length of hospitalization in the study group was also significantly lower than that in the control group (10.4 d vs. 13.7 d, P=0.000). Subgroup analysis of the study group showed that the incidence of VTE in patients with non-compliance, partial compliance, and good compliance was 56.7%, 5.8% and 2.8%, respectively (P=0.000). CONCLUSIONS Poor drug compliance leads to higher VTE occurrence. The information platform-based nursing can effectively improve the compliance of patients with hip fracture and thus significantly reduce the incidence of VTE.

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