Multiplanar reformation computed tomogram is better than MR imaging in decision making for apparently isolated fractures of the greater trochanter

Lipohemarthrosis of the Hip Joint in Apparently Isolated Greater Trochanter Fractures

Backgroud

Lipohemarthrosis in the hip joint, a critical indicator for detecting occult femoral neck or acetabular fractures, has not been reported in cases of isolated greater trochanter (IGT) fractures. This study retrospectively reviewed 3-dimensional computed tomography (3D-CT) images of what appeared to be IGT fractures to find out the frequency of lipohemarthrosis and its implication for the necessity of internal fixation.

Methods

From October 2004 to December 2019, 90 cases of suspected IGT fractures were evaluated using 3D-CT. After excluding 6 cases due to inadequate follow-up and 8 cases with poor imaging quality caused by metallic implants, 76 cases were included in the final analysis. The cohort consisted of 48 women and 28 men, with a mean age of 77 years (range, 39-97 years). The 3D-CT images were meticulously reviewed to identify lipohemarthrosis in the affected hip joints. Additionally, magnetic resonance (MR) images were available for 13 cases.

Results

Sixty-three cases were IGT fractures; no cortical disruption was detected in the intertrochanteric area on CT images. Of these, 56 cases were successfully treated conservatively. Lipohemarthrosis was detected in 5 cases (7.9%), of which 2 were successfully managed with conservative treatment. The remaining 13 cases were classified as incomplete intertrochanteric fractures, with anterior cortical disruption identified in the intertrochanteric area on CT images. Lipohemarthrosis was observed in 3 of these cases (21.3%). In all cases evaluated with MR imaging (10 IGT fractures and 3 incomplete intertrochanteric fractures), varying degrees of intramedullary intertrochanteric extension were observed. Among these, lipohemarthrosis was detected in only 2 cases of IGT fracture, where the intramedullary extension did not cross the midline on mid-coronal images. One case was surgically fixed, but the other case was treated conservatively with success. Notably, 4 cases with intertrochanteric extension crossing the midline did not exhibit lipohemarthrosis.

Conclusions

Lipohemarthrosis was more frequently observed in incomplete intertrochanteric fractures than in IGT fractures. However, the presence of lipohemarthrosis alone should not be regarded as an indication for internal fixation.

Surgical versus conservative treatment of greater trochanteric fractures with occult intertrochanteric fractures: Retrospective cohort study

BACKGROUND

Greater trochanter (GT) fractures are rare and frequently associated with occult intertrochanteric (IT) fractures. No consensus has been reached regarding whether surgical or conservative treatment is preferred for such fractures. The purpose of this study was to evaluate the clinical outcomes of surgical versus conservative treatment for coexistent GT and occult IT fractures.

MATERIALS AND METHODS

Between January 2006 and December 2021, we enrolled patients who were diagnosed with GT fracture on radiography or CT and underwent MRI to reveal occult IT fracture. Eligible patients were divided into two treatment groups: surgical and conservative treatment. The characteristics and outcomes of the patients were compared between the two groups.

RESULTS

Fifty patients were included in this study. There were 29 patients (3 male, 26 female; mean age: 84.45 ± 10.68 years) in the surgical treatment group and 21 patients (3 male, 18 female; mean age: 83.33 ± 9.34 years) in the conservative group, respectively. The demographic and clinical characteristics of the two groups were comparable, including sex, age, body mass index (BMI), percentage of extension into the IT area, days from injury to diagnosis, and activities of daily living (ADL) before injury. All 50 patients healed without displaced fractures, regardless of the percentage of extension into the IT area. There were no significant differences in the modified functional ambulation category scores between the two groups at one week, one month, and three months following the start of the treatment intervention (P = 0.653, 0.923, and 0.577, respectively). The length of hospital stay was 48.4 ± 5.97 days in the surgical treatment group and 50.6 ± 7.55 days in the conservative treatment group (P = 0.422). There was no significant difference in one-year mortality between surgical and conservative treatments (P = 0.219).

CONCLUSIONS

There were no significant differences in any outcome between the surgical and nonsurgical treatment groups. The results of the study suggested that coexistent GT and occult IT fractures may be managed conservatively without developing complete fractures, regardless of extension into the IT area.

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.

How can MRI change the treatment strategy in apparently isolated greater trochanteric fracture?

INTRODUCTION

The purpose of this study was to evaluate the proportion of greater trochanter (GT) fractures with occult extension to the intertrochanteric region on magnetic resonance imaging (MRI) among apparently isolated GT fractures and to investigate the use of MRI for formulating a treatment strategy in patients with isolated GT fractures.

PATIENTS AND METHODS

This retrospective cohort study reviewed 37 patients with isolated GT fractures on plain radiography. Surgical or conservative treatment was decided according to MRI findings. We divided patients into 3 groups according to the extension of the fracture line. In group 1, the fracture line was within the lateral one-third in the coronal plane. In group 2, the fracture line extended from the lateral one-third to the medial one-third. In group 3, the fracture line extended over the medial one-third and/or to the medial cortex of the femur. Conservative treatment was performed in groups 1 and 2, and surgical treatment was performed in group 3. The clinical results, radiography findings, and MRI findings were investigated.

RESULTS

MRI revealed hidden intertrochanteric fractures (groups 2 [n = 10] and 3 [n = 4]) in 38% of apparently isolated GT fractures on radiography. No displacement was found in groups 1 (n = 23) and 2. Of the 4 patients in group 3, 3 were treated surgically and achieved good functional results and 1 refused to undergo surgery and finally developed complete intertrochanteric fracture. This patient presented 5 days later with increased hip pain, and radiography demonstrated displacement of the fracture, prompting surgical intervention.

CONCLUSIONS

The evaluation of apparently isolated GT fractures using MRI can be useful to diagnose the extent of the occult fracture and determine the treatment strategy.

Is magnetic resonance imaging necessary in isolated greater trochanter fracture? A systemic review and pooled analysis

BACKGROUND

Isolated fractures of the greater trochanter (GT) of the femur are uncommon and few studies have assessed the diagnosis and appropriate therapeutic schedule for these fractures. The current data regarding assessment of isolated fractures of the GT are limited to a few reviews based on the experience of a single institution. Therefore, we asked the following questions: (1) what proportion of cases has an associated extension of the fracture into the intertrochanteric region in isolated GT fracture and (2) what are the treatment options and outcomes of GT fractures with occult intertrochanteric fractures.

METHODS

We conducted a systematic review of published studies that evaluated patients who displayed isolated GT fracture on routine radiographic examination and underwent a magnetic resonance imaging (MRI) scan because of the suspicion of extension into the intertrochanteric region. A structured literature review of multiple databases (PubMed, EMBASE, CINAHL, and Cochrane systematic reviews) referenced articles from 1950 to 2015.

RESULTS

A total of 110 patients were identified from 7 published studies. MRI documented isolated GT fractures diagnosed on initial radiographs in only 11 of 110 patients (10%). In 99 patients (90%), MRI examinations revealed extension of the fracture into the intertrochanteric region. Surgical fixation was necessary for 61 patients, with a pooled percentage of 55%. No complications were observed after surgery.

CONCLUSIONS

Our study has helped to elucidate further the assessment of isolated fracture of the GT. We believe that MRI is a reasonable option for patients presenting with isolated GT fracture on plain radiographs.