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

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.

BET 2: CT versus MRI for 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.

The use of MRI and CT in Imaging Occult Hip Fractures

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.