Posttraumatic painful hip: sonography as a screening test for occult hip fractures

An Umbrella Review and Updated Meta-Analysis of Imaging Modalities in Occult Scaphoid and Hip and Femoral Fractures

Background: Occult fractures may cause multiple morbidities. If occult fractures were detected earlier, complications may be preventable. This umbrella review and updated meta-analysis will aim to evaluate the use of imaging modalities in detecting occult scaphoid and hip fractures. Methods: The protocol for this study is available in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42024525388). The literature search started and ended on 17 March 2024. We searched seven academic databases: MEDLINE, Cochrane Library, Pubmed, Science Direct, Google Scholar, WHO International Clinical Trials Registry Platform, and The Joanna Briggs Institute (JBI) database. The meta-analysis was conducted with the STATA program using the "midas" command. Results: There are four systematic reviews evaluating occult hip and femoral fractures with 6174 patients and two reviews evaluating occult scaphoid fractures with 1355 patients. The prevalence of occult scaphoid fracture and occult hip and femoral fractures is 23.87% (95% CI 18.25-29.49) and 44.8% (95% CI 39.38-51.4), respectively. Magnetic resonance imaging (MRI) had the best posterior probability of positive likelihood ratio (LR+) with 95% and 96% and negative likelihood ratio (LR-) with 0.15% and 1% for both occult scaphoid and hip fractures, respectively, assuming a 25% baseline. MRI could both confirm and exclude occult hip fractures while it can only confirm occult scaphoid fractures. Bone scans are inappropriate for either type of occult fractures The level of evidence for occult scaphoid fracture is weak while it is suggestive for occult hip fractures. Conclusion: The findings strengthen the use of MRI after an initially negative radiograph fracture for occult hip and femoral fractures, with a CT scan as a viable second option.

Time to FOCUS - 'Palliative Medicine Point-of-Care Ultrasound'

Point-of-care diagnosis has become the need of the hour and along with its guided interventions, ultrasound could be utilised bedside in a palliative care patient. Point-of-care ultrasound (POCUS) in palliative care medicine is fast emerging and has varied applications ranging from performing bedside diagnostic evaluation to the performance of interventional paracentesis, thoracocentesis and chronic pain interventions. Handheld ultrasound devices have transformed the application of POCUS and should revolutionise the future of home-based palliative care. Palliative care physicians should be enabled to carry out bedside ultrasounds at home care and hospice setting for achieving rapid symptom relief. The aim of POCUS in palliative care medicine should be adequate training of palliative care physicians, transforming the applicability of this technology to OPD as well as community driven to achieve home outreach. The goal is towards empowering technology by reaching out to the community rather than the terminally ill patient transported for the hospital admission. Palliative care physicians should receive mandatory training in POCUS to enable diagnostic proficiency and early triaging. The inclusion of ultrasound machine in an outpatient palliative care clinic brings about value addition in rapid diagnosis. Limiting POCUS application to certain selected sub-specialities such as emergency medicine, internal medicine and critical care medicine should be overcome. This would need acquiring higher training as well as improvised skill sets to perform bedside interventions. Ultrasonography competency among palliative care providers proposed as palliative medicine point-of-care ultrasound (PM-POCUS) could be achieved by imparting dedicated POCUS training within the core curriculum.

Diagnostic accuracy of ultrasonography for occult femoral neck fracture

BACKGROUND

A delay in the diagnosis and treatment of an occult femoral neck fracture (OFNF) can negatively affect the subsequent quality of life. We investigated the diagnostic accuracy of ultrasonography for OFNF in patients confirmed with this condition by magnetic resonance imaging (MRI), and compared these results with other clinical findings.

METHODS

Ninety-four outpatients aged above 70 years with acute hip pain but without radiographic abnormal findings who were suspected of having an occult femoral neck fracture (11 men and 83 women with a mean age of 81.8 ± 6.0 years) were enrolled. Both ultrasonography and MRI were performed in all cases within 24 h. The ultrasonographic distance between the anterior aspect of the femoral neck and the anterior joint capsule (ultrasound joint swelling) was measured.

RESULTS

By MRI findings, 27 patients were assigned to an occult femoral neck fracture (OFNF) group (1 man, 26 women) and 67 patients to a non-OFNF group (10 men, 57 women). The mean ultrasound joint swelling in both groups was 7.53 ± 1.52 mm and 3.45 ± 0.89 mm, respectively (p = 0.006, 95% CI, 3.58-4.59). A cut-off value of 5.3 mm showed a sensitivity of 0.96 (0.89-0.96) and a specificity of 0.98 (0.92-1.00).

CONCLUSIONS

Ultrasonography shows very high diagnostic accuracy for occult femoral neck fracture. This modality can thus contribute to initial bed-side examinations for this condition in patients over 70 years with acute hip pain.

The Role of Point of Care Ultrasound (PoCUS) in Orthopaedic Emergency Diagnostics

Ultrasound has been described as the "stethoscope" of the radiologist; its ability to aid in clinical diagnosis with both static and dynamic imaging has allowed fast and accurate diagnosis. However, traditionally unlike a stethoscope, a large and bulky ultrasound machine made it difficult to use portably in a hospital environment where patients can be scattered across a hospital. With the development of innovative ultrasound technology, Point of Care Ultrasound (PoCUS) can readily be carried by a clinician to make a quick and timely diagnosis. In this review article we look at the uses of PoCUS within orthopaedic emergencies. Diagnosis in orthopaedics often requires further imaging beyond history taking, clinical examination and plain radiographs. In these cases PoCUS can be useful for ruling out occult fractures, diagnosing joint effusions and tendon ruptures. By aiding a speedy diagnosis, we can reduce unnecessary immobilisation, reduce inpatient stays, introduce early mobilisation and reduce harm to patients. With PoCUS becoming increasingly cheaper and more portable we feel this really can become the stethoscope of an orthopaedic surgeon.

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.

Initial assessment of femoral proximal fracture and acute hip arthritis using pocket-sized ultrasound: a prospective observational study in a primary care setting in Japan

BACKGROUND

Acute hip pain caused by femoral proximal fractures or acute hip arthritis requires imaging for accurate diagnosis. Although pocket-sized ultrasound (PsUS) offers several advantages over other imaging modalities, there is limited information regarding its use in diagnosing femoral proximal fractures or acute hip arthritis. Thus, we aimed to validate the diagnostic accuracy of PsUS for both disorders.

METHODS

In this prospective observational study, outpatients with acute hip pain were diagnosed according to a fixed procedure of the PsUS probe handling. We verified the diagnostic accuracy of PsUS findings (cortical discontinuity and joint fluid retention) and compared it with that of radiography, computed tomography, and magnetic resonance imaging.

RESULTS

Our study included 52 outpatients (mean age, 78.0 years; female, 88.5%). Of 26 patients diagnosed with femoral proximal fractures, 14 had femoral neck fractures and 12 had femoral trochanteric fractures. The sensitivity and specificity for identifying cortical discontinuity in femoral proximal fractures were 0.96 and 0.92, respectively. The sensitivity for identifying either cortical discontinuity or joint fluid retention in femoral proximal fractures or acute hip arthritis was 0.97.

CONCLUSIONS

Negative PsUS findings of cortical discontinuity and joint fluid retention in the hip are useful for ruling out femoral proximal fractures and acute hip arthritis. PsUS and radiography have comparable diagnostic accuracies, and PsUS could aid in the initial assessment of acute hip pain among the elderly in primary care settings.

Ultrasound of bone fractures

The World Health Organisation estimates only 33% of the world's population has local access to diagnostic imaging. Doctors operating in austere locations in Canada and Australia are using point-of-care ultrasound to differentiate between bone injury and soft tissue injury. Studies have demonstrated ultrasound to be a highly sensitive diagnostic tool for bone fracture. We present an ultrasound pictorial review of various bone fractures to demonstrate its value as an extension of the clinical examination in identifying fracture and to support the need for further imaging. Innovative and affordable ultrasound devices have been developed, which will improve accessibility to imaging.

The Frequency of Occult Intertrochanteric Fractures among Individuals with Isolated Greater Trochanteric Fractures

Purpose

Isolated greater trochanteric (GT) fractures are often identified using plain radiography of patients with post-traumatic hip pain. In many cases, the fracture extends to form an occult intertrochanteric fracture. We conducted a study to determine the frequency of occult intertrochanteric fractures in patients diagnosed with isolated GT fractures using plain radiographs.

Materials and Methods

Among 3,017 individuals who visited our emergency department with a trauma-induced pertrochanteric femur fracture between July 2004 and March 2018, 100 patients diagnosed with isolated GT fractures using plain radiographs were retrospectively analyzed. Patients were divided into two groups, those with: i) isolated GT fractures (group A) and ii) occult intertrochanteric fractures (group B). In addition, plain radiographs, magnetic resonance imaging results, and treatment methods were further analyzed in each group. If surgery treatment was needed, it was performed by one surgeon, and in all cases, a 2-hole dynamic hip screw was used.

Results

Among the 100 cases of isolated GT fractures diagnosed using plain radiograph, additional examinations revealed that 10 (10.0%) were suffering from isolated GT fractures alone, while the remaining 90 (90.0%) were further diagnosed with occult intertrochanteric fracture. Gender, age, mechanism of injury, and bone mineral density did not correlate with fracture type.

Conclusion

In our analysis, 90% of injuries initially diagnosed as isolated GT fractures were found to extend into occult intertrochanteric fractures upon further examination with additional imaging modalities. Therefore, additional evaluation should be performed to test for the potential presence of occult intertrochanteric fractures and to establish appropriate treatment plans.

The effectiveness of ultrasound in the detection of fractures in adults with suspected upper or lower limb injury: a systematic review and subgroup meta-analysis

Background

The aim of the present review is to assess the effectiveness of ultrasound (US) in the detection of upper and lower limb bone fractures in adults compared to a diagnostic gold standard available in secondary and tertiary care centres (e.g. radiography, CT scan or MRI).

Methods

The review followed PRISMA guidelines and used a database-specific search strategy with Medline, EMBASE and The Cochrane Library plus secondary sources (see supplementary material for completed PRISMA checklist). Diagnostic performance of ultrasound was assessed with a qualitative synthesis and a meta-analysis of two data subgroups.

Results

Twenty-six studies were included (n = 2360; fracture prevalence =5.3 % to 75.0%); data were organised into anatomical subgroups, two of which were subjected to meta-analysis. Sensitivity and specificity ranged from 42.11 − 100% and 65.0 − 100%, with the highest diagnostic accuracy in fractures of the foot and ankle. The pooled sensitivity and specificity of US was 0.93 and 0.92 for upper limb fractures (I² = 54.7 % ; 66.3%), and 0.83 and 0.93 for lower limb fractures (I² = 90.1 % ; 83.5%).

Conclusion

Ultrasonography demonstrates good diagnostic accuracy in the detection of upper and lower limb bone fractures in adults, especially in fractures of the foot and ankle. This is supported by pooled analysis of upper and lower limb fracture subgroups. Further research in larger populations is necessary to validate and strengthen the quality of the available evidence prior to recommending US as a first-line imaging modality for prehospital use.

Trial registration

The protocol is registered with the PROSPERO International register of systematic reviews: ID = CRD42017053640.

Electronic supplementary material

The online version of this article (10.1186/s12873-019-0226-5) contains supplementary material, which is available to authorized users.

Occult fractures of the proximal femur: imaging diagnosis and management of 82 cases in a regional trauma center

BACKGROUND

Occult hip fractures are often difficult to identify in busy trauma units. We aimed to present our institutions experience in the diagnosis and treatment of occult fractures around the hip and to help define a clinical and radiological management algorithm.

METHOD

We conducted a seven-year retrospective hospital medical record analysis. The electronic database was searched for ICD-10 CM codes S72.0 and S72.1 used for proximal femoral fractures upon patient discharge. We identified 34 (4.83 %) femoral neck fractures and 48 (4.42 %) trochanteric fractures labeled as occult.

RESULTS

The majority of the cases were diagnosed by primary MRI scan (57.4 %) and 12 were diagnosed by emergency CT scan (14.6 %). For the remaining cases the final diagnosis was confirmed by 72 h CT scan in 9 patients (representing 39 % of the false negative cases) or by MRI in the rest of 14 patients. MRI was best at detecting incomplete pertrochanteric fracture patterns (13.45 % of total) and incomplete fractures of the greater trochanter (3.65 % of total) respectively. It also detected the majority of Garden I femoral neck fractures (20.7 % of total). CT scanning accurately detected 100 % of Garden 2 fractures (2.44 %) and 25 % (3.65 %) of the complete pertrochanteric fractures (false negative 25 %).

CONCLUSION

Occult fractures should be suspected in all patients with traumatic onset of hip pain that is inconsistent with normal radiographic findings. MRI is the golden standard but not as readily available not as cheap and not quite as quick to perform as as a CT scan. The latter which in turn can provide falsely negative results in the first 24 h. Improved imaging protocols could expedite management and improve treatment.

Bilateral occult hip fracture

One 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.

Sonographically assisted percutaneous removal of screws in dynamization of the interlocking intramedullary nail

OBJECTIVES

Dynamization is a method of removing the interlocking screw(s) farthest from the fracture site for improving healing in femoral and tibial fractures that show delayed healing after static interlocking nailing. We describe a simple sonographically assisted technique for percutaneous dynamization of deep-seated impalpable screws.

METHODS

Between March 2001 and March 2005, 20 dynamization procedures were completed using the developed technique under the diagnosis of delayed healing or a nonunion at a mean of 4.8 months after index surgery. After adequately positioning the involved leg, the transducer was placed on the area of the inlet of the screw. Longitudinal and transverse sonographically scanned sections, used to show the head of the screw, were then marked on the skin where the two sections intersected. After this precise marking, a small incision on the mark allowed insertion of the screwdriver and easy percutaneous removal of the screw using only local anesthesia for pain control.

RESULTS

We removed 31 screws: 9 proximal femoral screws, 20 distal femoral screws, and 2 proximal tibial screws. The mean depth of the screws was 3.4 cm. The mean operation times were 1.6 minutes for the sonographic examination and 3.5 minutes for removal of one screw. No infections or morbidities were caused by the procedure.

CONCLUSIONS

Sonography is an effective tool for localizing a locked screw and facilitates percutaneous removal of screws under only local anesthesia for dynamization. This method needs no special instruments and reduces the time needed for dissecting the tissue and locating the screw.

Analysis of initial injury radiographs of occult femoral neck fractures in elderly patients: a pilot study

Diagnosis of occult hip fractures by initial radiographs remains challenging in the emergency department. Previously, the gold standard for accurate diagnosis of occult hip fractures was magnetic resonance imaging. This study used initial radiographs obtained in the emergency department to evaluate specific signs and measurements as diagnostic references for occult femoral neck fractures in elderly patients.Initial negative radiographs were reviewed for 2 groups of patients: a group with occult femoral neck fractures (n=16) and a group without fractures (n=32). Reviews of initial radiographs and all imaging studies were performed by a senior orthopedist (C-C.C.) and a radiologist (H-T.W.). Diagnostic signs included lateral, medial, anterior, and posterior signs; measurements included elevation of the fat pad and external rotation of the femur. The prevalence of occult femoral neck fracture was 3.3%. Initial radiographs of occult femoral neck fractures were not routinely negative; 14 (87.5%) of 16 patients with fractures had at least 1 radiographic sign. Using the positive lateral or posterior sign as the diagnostic reference, the sensitivity was 0.875 and the specificity was 0.906. When elevation of the fat pad was ⩾1.5 mm, the sensitivity was 0.867 and the specificity was 0.857 for the diagnosis of occult femoral neck fracture.The lateral and posterior signs and elevation of the fat pad ⩾1.5 mm on initial radiographs are recommended as diagnostic references for occult femoral neck fracture. These references are clearly defined and may offer important information for all clinicians and radiologists in the emergency department.

Common sonographic findings in the painful hip after hip arthroplasty

Diagnosing the cause of hip pain in patients with hip arthroplasty can be challenging because of the numerous possible causes of pain and artifacts caused by the prosthetic components on computed tomography and magnetic resonance imaging. Sonography plays an important role in the diagnosis and management of these patients because the soft tissues surrounding the prosthetic joint are not obscured by artifacts and because sonography enables hands-on examination of the painful site, dynamic evaluation of moving structures, and comparison with the opposite side. Another advantage of sonography is the ability to perform sonographically guided diagnostic and therapeutic procedures. In this pictorial essay, we highlight commonly encountered sonographic findings in patients with hip pain after hip arthroplasty.

Role of MRI in hip fractures, including stress fractures, occult fractures, avulsion fractures

MR imaging plays a vital role in the diagnosis and management of hip fractures in all age groups, in a large spectrum of patient groups spanning the elderly and sporting population. It allows a confident exclusion of fracture, differentiation of bony from soft tissue injury and an early confident detection of fractures. There is a spectrum of MR findings which in part is dictated by the type and cause of the fracture which the radiologist needs to be familiar with. Judicious but prompt utilisation of MR in patients with suspected hip fractures has a positive therapeutic impact with healthcare cost benefits as well as social care benefits.