The use of MRI and CT in Imaging 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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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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Use of Multislice CT for Investigation of Occult Geriatric Hip Fractures and Impact on Timing of Surgery

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459318821214 ◽

2019 ◽

Vol 10 ◽

pp. 215145931882121

Author(s):

John Williams ◽

Felix Allen ◽

Marta Kedrzycki ◽

Yathish Shenava ◽

Renu Gupta

Keyword(s):

Hip Fracture ◽

Computerized Tomography ◽

Hip Fractures ◽

Multislice Ct ◽

Clinical Excellence ◽

Timing Of Surgery ◽

First Line ◽

Initial Radiograph ◽

Magnetic Resonance Imaging Mri ◽

Occult Hip Fractures

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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Computed tomography-based diagnosis of occult fragility hip fractures offer shorter waiting times with no inadvertent missed diagnosis

Journal of Orthopaedic Surgery ◽

10.1177/2309499020932082 ◽

2020 ◽

Vol 28 (2) ◽

pp. 230949902093208

Author(s):

Gin Way Law ◽

Akshay Padki ◽

Kae Sian Tay ◽

Tet Sen Howe ◽

Joyce Suang Bee Koh ◽

...

Keyword(s):

Computed Tomography ◽

Hip Fracture ◽

Hip Fractures ◽

Waiting Times ◽

Cross Sectional ◽

Cancer History ◽

Surgical Delay ◽

Occult Hip Fracture ◽

Cross Sectional Imaging ◽

Sectional Imaging

Purpose: Surgical delay due to the wait for advanced cross-sectional imaging in occult fragility hip fracture management is not well studied. Our study aims to investigate computed tomography (CT) as an alternative to the gold standard magnetic resonance imaging (MRI) in occult hip fracture workup to decrease surgical delay. Methods: We conducted a retrospective review of all CTs and MRIs performed between 2015 and 2017 for patients with clinically suspected fragility hip fractures and negative plain radiographs to investigate surgical delay resulting from the wait for advanced imaging and representations due to missed fractures. Results: A total of 243 scans (42 CTs and 201 MRIs) were performed for occult hip fracture workup over the study timeframe, of which 49 patients (20%) had occult hip fractures [CT: 6 (14%), MRI: 43 (21%), p = 0.296)]. There were no readmissions for fracture in the 12 months following a negative scan. The CT group had shorter waiting times (CT: 29 ± 24 h, MRI: 44 ± 32 h, p = 0.004) without significantly reducing surgical delay (CT: 82 ± 36 h, MRI: 128 ± 58 h, p = 0.196). The MRI group had a higher number of patients with a cancer history ( p = 0.036), reflective of the practice for workup of possible metastases as a secondary intention. Conclusion: Advanced cross-sectional imaging wait times in occult hip fracture workup contribute significantly to surgical delay. Modern CT techniques are not inferior to MRI in detecting occult fractures and may be a suitable alternative in the absence of a cancer history if MRI cannot be obtained in a timely fashion or is contraindicated. Clinicians should utilize the more readily available imaging modality to reduce surgical delay.

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Systematic Review on the Functional Status of Elderly Hip Fracture Patients using Katz Index of Activity of Daily Living (Katz ADL) Score

IIUM Medical Journal Malaysia ◽

10.31436/imjm.v15i2.397 ◽

2020 ◽

Vol 15 (2) ◽

Author(s):

Sharkawi MA ◽

Zulfarina SM ◽

Aqilah-SN SMZ ◽

Isa NM ◽

Sabarul AM ◽

...

Keyword(s):

Hip Fracture ◽

Hip Fractures ◽

Daily Living ◽

Elderly Population ◽

Evidence Based ◽

Activity Of Daily Living ◽

Inclusion Criteria ◽

Katz Index ◽

One Year ◽

Careful Screening

Hip fractures cases are common in elderly population. After a hip fracture, around 80% of patients were unable to carry out at least one independent activity of daily living (ADL). This review attempted to provide an evidence-based literature on ADL of elderly hip fracture patients. A computerised literature search using Medline (OVID) and Scopus databases were conducted to identify relevant studies on ADL of elderly hip fracture patients that was assessed with Katz ADL score. Only articles that fulfilled the inclusion criteria were included in this review. Initial search identified 314 potentially relevant articles but after careful screening, only 5 full-text articles were selected for the present review. Three studies showed an increase dependent level of the patients’ ADL after hip fractures. Two studies showed not more than half of the patients were unable to regain their pre-fracture ADL level after one year of hip fracture incidence. Feeding/eating showed the highest independent activity while bathing was the lowest independent activity among patients. In conclusion, elderly hip fracture patients have declined ADL with the risk that they may never regain their pre-fracture ADL level.

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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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Prior Admissions as a Risk Factor for Readmission in Patients Surgically Treated for Femur Fractures: Implications for a Potential Hip Fracture Bundle

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459321996169 ◽

2021 ◽

Vol 12 ◽

pp. 215145932199616

Author(s):

Robert Erlichman ◽

Nicholas Kolodychuk ◽

Joseph N. Gabra ◽

Harshitha Dudipala ◽

Brook Maxhimer ◽

...

Keyword(s):

Logistic Regression ◽

Regression Analysis ◽

Hip Fracture ◽

Logistic Regression Analysis ◽

Hip Fractures ◽

Surgical Procedure ◽

Hospital Admissions ◽

Fracture Care ◽

Increased Risk ◽

Payment Models

Introduction: Hip fractures are a significant economic burden to our healthcare system. As there have been efforts made to create an alternative payment model for hip fracture care, it will be imperative to risk-stratify reimbursement for these medically comorbid patients. We hypothesized that patients readmitted to the hospital within 90 days would be more likely to have a recent previous hospital admission, prior to their injury. Patients with a recent prior admission could therefore be considered higher risk for readmission and increased cost. Methods: A retrospective chart review identified 598 patients who underwent surgical fixation of a hip or femur fracture. Data on readmissions within 90 days of surgical procedure and previous admissions in the year prior to injury resulting in surgical procedure were collected. Logistic regression analysis was used to determine if recent prior admission had increased risk of 90-day readmission. A subgroup analysis of geriatric hip fractures and of readmitted patients were also performed. Results: Having a prior admission within one year was significantly associated (p < 0.0001) for 90-day readmission. Specifically, logistic regression analysis revealed that a prior admission was significantly associated with 90-day readmission with an odds ratio of 7.2 (95% CI: 4.8-10.9). Discussion: This patient population has a high rate of prior hospital admissions, and these prior admissions were predictive of 90-day readmission. Alternative payment models that include penalties for readmissions or fail to apply robust risk stratification may unjustly penalize hospital systems which care for more medically complex patients. Conclusions: Hip fracture patients with a recent prior admission to the hospital are at an increased risk for 90-day readmission. This information should be considered as alternative payment models are developed for hip fracture care.

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The impact of COVID-19 infection on hip fracture 30-day mortality

Trauma ◽

10.1177/1460408620949725 ◽

2021 ◽

pp. 146040862094972

Author(s):

Ahmed Fadulelmola ◽

Rob Gregory ◽

Gavin Gordon ◽

Fiona Smith ◽

Andrew Jennings

Keyword(s):

Hip Fracture ◽

Hip Fractures ◽

Hospital Admissions ◽

The Elderly ◽

Primary Outcome Measure ◽

Time To Death ◽

Significant Difference ◽

The Mean ◽

The Impact ◽

Mean Time

Introduction: A novel virus, SARS-CoV-2, has caused a fatal global pandemic which particularly affects the elderly and those with comorbidities. Hip fractures affect elderly populations, necessitate hospital admissions and place this group at particular risk from COVID-19 infection. This study investigates the effect of COVID-19 infection on 30-day hip fracture mortality. Method: Data related to 75 adult hip fractures admitted to two units during March and April 2020 were reviewed. The mean age was 83.5 years (range 65–98 years), and most (53, 70.7%) were women. The primary outcome measure was 30-day mortality associated with COVID-19 infection. Results: The COVID-19 infection rate was 26.7% (20 patients), with a significant difference in the 30-day mortality rate in the COVID-19-positive group (10/20, 50%) compared to the COVID-19-negative group (4/55, 7.3%), with mean time to death of 19.8 days (95% confidence interval: 17.0–22.5). The mean time from admission to surgery was 43.1 h and 38.3 h, in COVID-19-positive and COVID-19-negative groups, respectively. All COVID-19-positive patients had shown symptoms of fever and cough, and all 10 cases who died were hypoxic. Seven (35%) cases had radiological lung findings consistent of viral pneumonitis which resulted in mortality (70% of mortality). 30% ( n = 6) contracted the COVID-19 infection in the community, and 70% ( n = 14) developed symptoms after hospital admission. Conclusion: Hip fractures associated with COVID-19 infection have a high 30-day mortality. COVID-19 testing and chest X-ray for patients presenting with hip fractures help in early planning of high-risk surgeries and allow counselling of the patients and family using realistic prognosis.

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Characteristics and Outcomes of Hip Fracture Patients Hospitalized in an Orthogeriatric Unit Versus an Orthopedic Department: A Retrospective Cohort Study

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459320986299 ◽

2021 ◽

Vol 12 ◽

pp. 215145932098629 ◽

Cited By ~ 1

Author(s):

Yulia Bugaevsky ◽

Yochai Levy ◽

Avital Hershkovitz ◽

Irena Ocheretny ◽

Adaya Nissenholtz ◽

...

Keyword(s):

Older Adults ◽

Cohort Study ◽

Hip Fracture ◽

Hip Fractures ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Functional Independence ◽

Functional Improvement ◽

Orthopedic Department ◽

Successful Recovery

Introduction: Hip fractures are a significant health risk in older adults and a major cause of morbidity, functional decline and mortality. Our aim was to compare clinical outcomes of older patients hospitalized in an ortho-geriatric (OG) unit to those hospitalized in an orthopedic department (OD) for surgical treatment of a hip fracture. Methods: A retrospective cohort study of hip fractured patients hospitalized between 2015-2016 in a single tertiary university-affiliated medical center. Included were patients aged 65 and older who had undergone hip fracture surgery and were admitted to either a geriatric or orthopedic ward. Results: 441 patients met the inclusion criteria (195 in the OG unit, 246 in the OD); 257 were transferred to an affiliated geriatric center hospital (107 from the OG unit and 127 from the OD) for rehabilitation. Patients in the OG unit were older, more cognitively and functionally impaired and with more comorbidities. The 1-year mortality rate was significantly lower in the OD group (OR 0.32, CI 95% 0.19-0.53, p < 0.001), however, after propensity matching, the 30-day and 1 year mortality rates were similar in both groups. No difference was found in the rehabilitation length of stay between the groups. The functional independence measure improvement was similar in both groups, with a non-significant trend toward better functional improvement among OG unit patients. Conclusions: Despite the higher complexity of patients, worse baseline functional capacity in the OG unit, improvement after rehabilitation was similar in both groups. These results demonstrate the advantages of the OG unit in treating and stabilizing frail older adults, thus maximizing their chances for a successful recovery after hip fractures. Level of Evidence: Level IV

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