Objective sound wave amplitude measurement generated by a tuning fork. An analysis of its use as a diagnostic tool in suspected femoral neck fractures

Ipsilateral proximal and shaft femoral fractures treated with bridge-link type combined fixation system

BACKGROUND

Although many treatments for ipsilateral proximal and shaft femoral fractures have been developed, controversy exists regarding their optimal management. The purpose of this retrospective study was to discuss the effectiveness of the bridge-link type combined fixation system (BCFS) and evaluate functional outcomes in treating patients with these complex fractures.

PATIENTS AND METHODS

We retrospectively reviewed 14 cases of ipsilateral proximal and shaft femoral fractures treated from January 2012 to December 2016. All cases were treated by BCFS combined with minimally invasive percutaneous plate osteosynthesis (MIPPO). Clinical and radiographic data were collected during regular post-operative follow-up visits. Functional outcomes were determined according to the Friedman and Wyman scoring system.

RESULTS

The proximal femoral fractures were emergency diagnoses in 11 cases and delayed diagnoses in 3 cases. The delay time was 5-6 days, with an average of 5.3 days. The mean operation time was 179.6 min (range 135-231 min) with a blood loss volume that ranged from 430 to 535 ml (average 483.6 ml). Follow-up was conducted in 13 cases between 9 and 30 months post-operation, with an average follow-up time of 17.3 months. The proximal femoral fractures were united in 12 cases at the final follow-up. One case had nonunion 13 months after the operation, underwent valgus intertrochanteric osteotomy, and healed 6 months later. The femoral shaft fractures obtained rigid union at the latest follow-up in 12 cases. One case endured nonunion 12 months after the operation. After the revision surgery and iliac bone grafting, the fracture healed 6 months later. Eight of the cases had good functional results, 4 had fair results, and results were poor in 1 case at the final follow-up.

CONCLUSIONS

The treatment of ipsilateral proximal femoral and shaft fractures with BCFS in combination with MIPPO demonstrated a high likelihood of union for both fractures and good functional results.

Use of Advanced Imaging for Radiographically Occult Hip Fracture in Elderly Patients: A Systematic Review and Meta-Analysis

Background The overall rate of hip fractures not identified on radiographs but that require surgery (ie, surgical hip fractures) remains unclear in elderly patients who are suspected to have such fractures based on clinical findings. Moreover, the importance of advanced imaging in these patients has not been comprehensively assessed. Purpose To estimate the frequency of radiographically occult hip fracture in elderly patients, to define the higher-risk subpopulation, and to determine the diagnostic performance of CT and bone scanning in the detection of occult fractures by using MRI as the reference standard. Materials and Methods A literature search was performed to identify English-language observational studies published from inception to September 27, 2018. Studies were included if patients were clinically suspected to have hip fracture but there was no radiographic evidence of surgical hip fracture (including absence of any definite fracture or only presence of isolated greater trochanter [GT] fracture). The rate of surgical hip fracture was reported in each study in which MRI was used as the reference standard. The pooled rate of occult fracture, diagnostic performance of CT and bone scanning, and strength of evidence (SOE) were assessed. Results Thirty-five studies were identified (2992 patients; mean age, 76.8 years ± 6.0 [standard deviation]; 66% female). The frequency of radiographically occult surgical hip fracture was 39% (1110 of 2835 patients; 95% confidence interval [CI]: 35%, 43%) in studies of patients with no definite radiographic fracture and 92% (134 of 157 patients; 95% CI: 83%, 98%) in studies of patients with radiographic evidence of isolated GT fracture (moderate SOE). The frequency of occult fracture was higher in patients aged at least 80 years (44%, 529 of 1184), those with an equivocal radiographic report (58%, 71 of 126), and those with a history of trauma (41%, 977 of 2370) (moderate SOE). CT and bone scanning yielded comparable diagnostic performance in the detection of radiographically occult hip fracture (P = .67), with a sensitivity of 79% and 87%, respectively (low SOE). Conclusion Elderly patients with acute hip pain and negative or equivocal findings at initial radiography have a high frequency of occult hip fractures. Therefore, the performance of advanced imaging (preferably MRI) may be clinically appropriate in all such patients. © RSNA, 2020 Online supplemental material is available for this article.

Hip bone marrow edema presenting as low back pain: a case report

Background: Nonspecific low back pain (LBP) is frequently managed by physiotherapists. However, physiotherapists in a direct access setting may encounter patients with serious medical conditions, such as Bone Marrow Edema Syndrome (BMES) of the hip with symptoms mimicking LBP. To our knowledge, this is the first case to describe hip BMES presenting as LBP. Diagnosis was based on the patient's symptoms in conjunction with magnetic resonance imaging (MRI). In order to avoid misdiagnosing the patient, primary care clinicians should be aware that BMES can mimic nonspecific LBP. Objective: To present a rare clinical presentation of BMES of the hip mimicking nonspecific LBP. To the best of the author's knowledge, this is the first case to describe hip BMES presenting as mechanical nonspecific LBP. Case presentation: This case report describes the history, examination findings, and clinical reasoning used for a patient with LBP as a chief complaint. Furthermore, the clinical presentation (i.e. pain location and its changes related to load) and the symptoms behavior (i.e. immediate symptoms decrease after few hip treatment sessions and quick worsening of the hip pain related to loading activities) after two treatment sessions increased the suspicion of an underlying medical condition of the hip joint and lead to the decision for additional evaluation. A MRI showed a serious hip BMES. Conclusions: This case report highlights the importance of including a comprehensive and continuous differential diagnostic process throughout the treatment period, looking for those risk factors (i.e. red flags) that warrant further investigation and referral to the appropriate physician. Physiotherapy diagnosis should include clinical reasoning, clinical presentation, and symptom behavior in addition to appropriate referral for medical assessment and diagnostic imaging when appropriate. Physiotherapists working within a direct access environment have the competence and responsibility to participate with other health professionals in the differential diagnose process especially for patients presenting with serious pathology mimicking musculoskeletal disorders.

Is the Patellar Pubic Percussion Test useful to diagnose only femur fractures or something else? Two case reports

In the literature, the utility of the Patellar Pubic Percussion Test (PPPT) to diagnose occult fractures of the femur is well described. However, up to now there are no studies demonstrating the efficacy of this test in recognizing fractures of the pelvis. In this two case report a positive PPPT allowed the therapist to recognize clinical conditions requiring caution, protecting patients from a potentially unsuitable treatment. Both patients had a negative pelvis and femur x-ray after a fall, but the clinical findings and a positive PPPT lead the physiotherapist to suggest further examinations. In these two cases the PPPT seemed to be a useful diagnostic tool to identify periacetabular, ileo-pubic and ischio-pubic ramus fractures. These findings suggest that PPPT could be positive even for a bone lesion in any of the transit points of the vibration, from the patella to the pubic symphysis.

Novel approach to the diagnosis of fractures in an austere environment using a stethoscope and a cellular phone

BACKGROUND

Fracture diagnosis in the austere environment where radiographic tests are not available can be a challenge. In the past, a diagnostic technique has been described using a tuning fork and stethoscope to assess decreased sound conduction in the fractured extremity. In this study, we evaluate the use of a cellular phone's vibrate function and a stethoscope to limit equipment carried by expeditionary practitioners.

OBJECTIVE

The purpose of this study was to evaluate the accuracy of fracture diagnosis using a cellular phone and stethoscope.

METHODS

This is a pilot study to assess the usefulness of the above technique before clinical implementation. In 3 cadavers, we created fractures of the humerus and femur. Twenty-seven emergency medicine residents and an attending physician performed the diagnostic technique.

RESULTS

Overall, the use of the cellular phone and stethoscope resulted in a sensitivity of 73% (95% confidence interval [CI]: 0.64 to 0.81) and a specificity of 83% (95% CI: 0.77 to 0.88), with a positive predicted value of 68% (95% CI: 0.59 to 0.77) and a negative predicted value of 86% (95% CI: 0.81 to 0.90). Positive likelihood ratio was 4.3, and negative likelihood ratio was 0.32.

CONCLUSIONS

The use of a cellular phone and stethoscope may be a useful tool for the diagnosis of fractures in the austere environment. However, further study is needed to validate these findings in the clinical environment.