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Yao J, Jiang W, Zhang H, Fan Z, Zhang W, Zhuang S, Wang J. Visual assessment and quantitative analysis of bone marrow edema in young and middle-aged versus elderly patients with vertebral compression fracture by spectral CT. Acta Radiol 2024; 65:49-55. [PMID: 36575593 DOI: 10.1177/02841851221146977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND For the diagnosis of bone marrow edema (BME), spectral computed tomography (CT) has emerged as a promising technique. PURPOSE To study the different performances of spectral CT in the diagnosis of vertebral BME in young and middle-aged versus elderly patients. MATERIAL AND METHODS Magnetic resonance imaging (MRI) was used as the gold standard. To determine the existence of BME, spectral CT color-coded images of the vertebral bodies of 82 patients with vertebral compression fractures (VCFs) were visually inspected. A quantitative analysis of the spectral CT vertebral water concentration in the diagnosis of BME was performed using a receiver operating characteristic (ROC) curve. Patients were divided into two groups for comparison: the young and middle-aged group; and the elderly group. RESULTS The sensitivity and specificity for visual assessment were 83.7% and 98.3%, respectively, in the young and middle-aged group and 96.8% and 98.2%, respectively, in the elderly group. The elderly group had a higher sensitivity than the young and middle-aged group (P < 0.05). With a threshold of 1046.2 mg/cm3, the ROC curve for the young and middle-aged group displayed an area under the curve (AUC) of 0.870, sensitivity of 86.0%, and specificity of 81.4%. The threshold of 1031.4 mg/cm3 yielded a sensitivity of 95.2% and a specificity of 98.4%, and the AUC of the elderly group was 0.997. The elderly group had a higher level of specificity than the young and middle-aged group (P < 0.05). CONCLUSION Spectral CT can reliably diagnose BME in VCFs, and it performs better in elderly people than in young and middle-aged people.
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Affiliation(s)
- Junpeng Yao
- Department of Radiology, Changzhou Municipal Hospital of Traditional Chinese Medicine, Changzhou, PR China
| | - Wanli Jiang
- First School of Clinical Medicine, Shandong University of Traditional Chinese Medicine, Jinan, PR China
| | - Hong Zhang
- Department of Radiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, PR China
| | - Zijian Fan
- Department of Radiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, PR China
| | - Wei Zhang
- Department of Radiology, Changzhou Municipal Hospital of Traditional Chinese Medicine, Changzhou, PR China
| | - Shunda Zhuang
- Department of Radiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, PR China
| | - Jianguo Wang
- Department of Radiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, PR China
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Bökeler U, Liener U, Vogeley N, Mayer B, Horsch C, Tröster F, Eschbach D, Ruchholtz S, Knauf T. Value of Proximal Femur Geometry in Predicting Occult Hip Fracture. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1987. [PMID: 38004036 PMCID: PMC10673107 DOI: 10.3390/medicina59111987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/02/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Patients with occult hip fractures are a difficult subgroup to treat. MRI is the gold standard for diagnosing occult proximal femur fractures but is costly and may not be readily available in an emergency setting. The purpose of this study was to determine whether changes in the proximal femur geometry can predict the likelihood of an occult hip fracture in patients presenting with hip pain following a ground-level fall. Material and Methods: Patients admitted to the hospital with a clinical suspicion of a hip fracture but initial negative radiographs over a seven-year period were included. All patients were additionally investigated with an MRI scan, and retrospectively, six radiologic parameters were obtained on plain radiographs: The cortical thickness index (CTI), the canal to calcar ratio (CCR), the canal flare index (CFI), the morphological cortical index (MCI), the canal bone ratio (CBR) and the canal bone aria ratio (CBAR). Subsequently the result of the plain radiographic indices of the patients with a negative MRI (Group A, no occult fracture) were compared to those with a positive MRI (Group B, occult fracture). Results: A total of 78 patients (59 female, 19 male) could be included in the study. The mean age was 82 years. The univariate analyses revealed a poor predictive ability of all radiological parameters with AUC values ranging from 0.515 (CBR) to 0.626 (CTI), whereas a multivariate prognostic model demonstrated improved prognosis (AUC = 0.761) for the CTI (p = 0.024), CBAR (p = 0.074) and CRR (p = 0.081) as the most promising predictive radiological parameters. Conclusions: Single radiologic indices obtained from conventional X-rays of the proximal femur have a weak predictive value in detecting occult fractures of the hip and cannot be used as clinical decision-making factors.
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Affiliation(s)
- Ulf Bökeler
- Department for Orthopaedics and Trauma Surgery, Marienhospital Stuttgart, Böheimstrasse 37, 70199 Stuttgart, Germany
| | - Ulrich Liener
- Department for Orthopaedics and Trauma Surgery, Marienhospital Stuttgart, Böheimstrasse 37, 70199 Stuttgart, Germany
| | - Nils Vogeley
- Department for Orthopaedics and Trauma Surgery, Marienhospital Stuttgart, Böheimstrasse 37, 70199 Stuttgart, Germany
| | - Benjamin Mayer
- Department for Epidemiology and Medical Biometry, University of UIm, 89081 Ulm, Germany; (B.M.); (C.H.)
| | - Cornelia Horsch
- Department for Epidemiology and Medical Biometry, University of UIm, 89081 Ulm, Germany; (B.M.); (C.H.)
| | - Fridolin Tröster
- Department for Diagnostic and Interventional Radiology, Marienhospital Stuttgart, 70199 Stuttgart, Germany
| | - Daphne Eschbach
- MVZ Hessisch Lichtenau e.v., Kaufungen, 34123 Kassel, Germany
| | - Steffen Ruchholtz
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, 35043 Marburg, Germany
| | - Tom Knauf
- Orthopaedische Klinik Hessisch Lichtenau, 37235 Hessisch Lichtenau, Germany;
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Mennen AHM, Blokland AS, Maas M, van Embden D. Imaging of pelvic ring fractures in older adults and its clinical implications-a systematic review. Osteoporos Int 2023; 34:1549-1559. [PMID: 37286662 PMCID: PMC10427539 DOI: 10.1007/s00198-023-06812-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/26/2023] [Indexed: 06/09/2023]
Abstract
Identifying the full scope of pelvic fracture patterns in older adults has gained clinical importance since the last decennium. CT is recommended as the golden standard; however, MRI has even greater diagnostic accuracy. Dual energy computed tomography (DECT) is a new and promising imaging technique, but the diagnostic accuracy in the context of pelvic fragility fractures (FFPs) has not been widely established. The aim was to provide insight into the diagnostic accuracy of different imaging techniques and the relevance for clinical practice. A systematic search was performed in the PubMed database. All studies that reported on CT, MRI or DECT imaging techniques in older adults who suffered a pelvic fracture were reviewed and, if relevant, included. Eight articles were included. In up to 54% of the patients, additional fractures were found on MRI compared to CT, and in up to 57% of the patients on DECT. The sensitivity of DECT for posterior pelvic fracture detection was similar to MRI. All patients without fractures on CT appeared to have posterior fractures on MRI. After additional MRI, 40% of the patients had a change of classification. DECT and MRI showed very similar results in terms of diagnostic accuracy. Over a third of all patients appear to have a more severe fracture classification after MRI, the majority changing to Rommens type 4. However, in only a few patients who changed of fracture classification, a change of therapy was advised. This review suggests that MRI and DECT scans are superior in diagnosing FFPs.
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Affiliation(s)
- Anna H M Mennen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Movement Sciences, Amsterdam, The Netherlands.
| | - Alida S Blokland
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Mario Maas
- Amsterdam Movement Sciences, Amsterdam, The Netherlands
- Department of Radiology & Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Daphne van Embden
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Amsterdam, The Netherlands
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Lee JY, Oya A, Tsuji O, Umezu T, Kanaji A, Niki Y, Nakamura M, Matsumoto M. Occult proximal femoral fracture with radiating leg pain masquerading as sciatica: a case report. J Med Case Rep 2023; 17:216. [PMID: 37226262 DOI: 10.1186/s13256-023-03951-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 04/26/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Occult proximal femoral fractures do not appear as fracture lines in radiographs, causing misdiagnosis and delayed diagnosis unless additional imaging studies, such as computed tomography or magnetic resonance imaging, are performed. Here, we present a 51-year-old male with an occult proximal femoral fracture who experienced radiating unilateral leg pain that took 3 months to be diagnosed because his symptoms mimicked lumbar spine disease. CASE PRESENTATION A 51-year-old Japanese male experienced persistent lower back and left thigh pain after falling off a bicycle, and was referred to our hospital 3 months thereafter. Whole-spine computed tomography and magnetic resonance imaging revealed minute ossification of the ligamentum flavum at T5/6 without spinal nerve compression, but this did not explain his leg pain. Additional magnetic resonance imaging of the hip joint revealed a fresh left proximal femoral fracture without displacement. He underwent surgery for in situ fixation using a compression hip screw. Post-surgical pain relief was immediate. CONCLUSIONS Misdiagnosis of occult femoral fractures as lumbar spinal disease may occur if distally radiating referred pain is present. Hip joint disease should be considered as a differential diagnosis in cases of sciatica-like pain with an unknown spinal origin and no specific findings on spinal computed tomography or magnetic resonance imaging accounting for the leg pain, especially following trauma.
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Affiliation(s)
- Ji-Yeon Lee
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi,, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Akihito Oya
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi,, Shinjuku-Ku, Tokyo, 160-8582, Japan.
| | - Osahiko Tsuji
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi,, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Taro Umezu
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi,, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Arihiko Kanaji
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi,, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Yasuo Niki
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi,, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi,, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi,, Shinjuku-Ku, Tokyo, 160-8582, Japan
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Strong semantic segmentation for Covid-19 detection: Evaluating the use of deep learning models as a performant tool in radiography. Radiography (Lond) 2023; 29:109-118. [PMID: 36335787 PMCID: PMC9595354 DOI: 10.1016/j.radi.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION With the increasing number of Covid-19 cases as well as care costs, chest diseases have gained increasing interest in several communities, particularly in medical and computer vision. Clinical and analytical exams are widely recognized techniques for diagnosing and handling Covid-19 cases. However, strong detection tools can help avoid damage to chest tissues. The proposed method provides an important way to enhance the semantic segmentation process using combined potential deep learning (DL) modules to increase consistency. Based on Covid-19 CT images, this work hypothesized that a novel model for semantic segmentation might be able to extract definite graphical features of Covid-19 and afford an accurate clinical diagnosis while optimizing the classical test and saving time. METHODS CT images were collected considering different cases (normal chest CT, pneumonia, typical viral causes, and Covid-19 cases). The study presents an advanced DL method to deal with chest semantic segmentation issues. The approach employs a modified version of the U-net to enable and support Covid-19 detection from the studied images. RESULTS The validation tests demonstrated competitive results with important performance rates: Precision (90.96% ± 2.5) with an F-score of (91.08% ± 3.2), an accuracy of (93.37% ± 1.2), a sensitivity of (96.88% ± 2.8) and a specificity of (96.91% ± 2.3). In addition, the visual segmentation results are very close to the Ground truth. CONCLUSION The findings of this study reveal the proof-of-principle for using cooperative components to strengthen the semantic segmentation modules for effective and truthful Covid-19 diagnosis. IMPLICATIONS FOR PRACTICE This paper has highlighted that DL based approach, with several modules, may be contributing to provide strong support for radiographers and physicians, and that further use of DL is required to design and implement performant automated vision systems to detect chest diseases.
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Additional Imaging is of Limited Value in Traumatic Hip Fractures With a History of Distant Malignancy and No Suspicious Lesion on Plain Radiographs. J Orthop Trauma 2022; 36:593-598. [PMID: 35605110 DOI: 10.1097/bot.0000000000002410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the value of obtaining additional preoperative imaging in patients with a traumatic hip fracture and a history of malignancy in whom plain radiographs show no lesion suspicious for metastases. DESIGN Retrospective review. SETTING Teaching NHS Trust in the United Kingdom, over an 8-year period treating 4421 hip fractures. PATIENTS/PARTICIPANTS Three hundred sixty-seven patients with hip fracture and a history of malignancy at a site distant to the hip. Three hundred thirty patients had a history of trauma and no lesion on the plain radiograph suspicious for metastases. MAIN OUTCOMES MEASUREMENTS Whether obtaining additional imaging preoperatively (MRI, CT, and bone scan) identified metastases or affected management. RESULTS 32/330 patients had further preoperative imaging, none of which demonstrated a pathological fracture secondary to malignancy. On follow-up, 3/330 (0.9%) cases were found to have occult metastasis at the hip fracture site. All 3 had only plain radiographs before surgery. In 2, this was identified on histological examination of intraoperative samples, and in 1, radiologically as a metastatic metaphyseal lesion 18 months after a hemiarthroplasty. Only in the latter case, preoperative identification of hip metastasis could have altered surgical management. Patients undergoing further preoperative imaging waited significantly longer for surgery (35 ± 26 vs. 51 ± 26 hours, P = 0.0011). CONCLUSIONS In the absence of a suspicious metastatic lesion on initial plain radiographs, further preoperative imaging is unlikely to identify a lesion that will affect management and confers significant delays to surgery. Sending intraoperative histological samples may help guide postoperative oncological management, but further work is needed to prove its utility. LEVEL OF EVIDENCE Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Occult Fracture of the Fibula: One Case Report. Orthop Nurs 2022; 41:371-373. [PMID: 36108246 PMCID: PMC9512230 DOI: 10.1097/nor.0000000000000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Occult fibula fracture in adults is a fairly rare disease. It is easy to overlook or misdiagnose, resulting in delayed treatment and serious sequelae, as well as medical conflicts. We describe a case of concealed distal fibula fracture. The radiograph revealed no visible abnormalities at first. Finally, the occult fibula fracture was confirmed by magnetic resonance imaging and the patient received timely, correct, and reasonable treatment after diagnosis. This case raises our awareness of occult fibula fractures that are easily missed, and it deserves to be shared.
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Tougas C, Brimmo O. Common and Consequential Fractures That Should Not Be Missed in Children. Pediatr Ann 2022; 51:e357-e363. [PMID: 36098608 DOI: 10.3928/19382359-20220706-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Missed or delayed diagnosis of fractures in children is not uncommon owing to their immature skeletons, unique fracture patterns, and distinctive radiologic findings. The term occult is used to describe radiographically subtle fractures. Some of these fractures can be associated with excellent outcomes despite the pitfalls of delayed diagnosis. However, a subset of these injuries have more guarded prognoses when missed, despite their harmless radiographic appearance. A high index of suspicion should be maintained when treating pediatric extremity injuries with clinical findings disproportionate to a benign-appearing radiograph. Moreover, overreliance on radiology reports can perpetuate diagnostic error. In cases of discrepancy, timely follow-up for repeat examination or immediate advanced imaging can help avoid missed diagnoses. Most critically, the one diagnosis not to miss is nonaccidental trauma, as continued exposure to abuse puts the child at risk of further injury and death. [Pediatr Ann. 2022;51(9):e357-e363.].
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Sundkvist J, Sjöholm P, Pejic A, Wolf O, Sköldenberg O, Rogmark C, Mukka S. Clinical outcomes of patients with Garden I and II femoral neck fractures as verified on MRI: a retrospective case series. BMC Musculoskelet Disord 2022; 23:144. [PMID: 35151282 PMCID: PMC8840676 DOI: 10.1186/s12891-022-05088-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 02/03/2022] [Indexed: 11/12/2022] Open
Abstract
Background Between 2 to 10% of non-displaced femoral neck fractures (nFNF) cannot be diagnosed on plain radiographs and require further imaging investigation to be detected or verified. These fractures are referred to as occult hip fractures. This study aimed to report treatment failures, reoperations and mortality in a consecutive series of occult femoral neck fractures (FNF) treated with internal fixation (IF). Methods A retrospective multicenter study was performed based on a consecutive series of patients aged ≥ 60 years with an occult magnetic resonance imaging (MRI) verified Garden I and II FNF sustained after a trauma and treated with primary IF. We included 93 patients with a minimum 2-year follow-up. Radiographic assessment encompassed pre- and postoperative tilt, implant inclination, MRI and treatment failure. Data on reoperation and mortality were collected. Treatment failure was defined as fixation failure, nonunion, avascular necrosis or posttraumatic osteoarthritis. Results The study comprised of 93 patients (72% women, 67/93) with a mean age of 82 (range, 60–97) years. Overall, 6 (6%) patients had major reoperations. 2 (2%) had minor reoperations. One-month mortality was 7%, 1-year mortality was 20% and 2-year mortality was 31%. Conclusion This multicenter cohort study identifies a subgroup of elderly patients with MRI verified Garden I and II FNFs sustained after trauma, i.e. occult fractures. These fractures seem to have a lower complication rate compared to nFNF identified on plain radiographs. Level of evidence Prognostic Level V. See Instructions to Authors for a complete description of levels of evidence.
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Low YL, Finkelstein E. Cost-Effective Analysis of Dual-Energy Computed Tomography for the Diagnosis of Occult Hip Fractures Among Older Adults. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1754-1762. [PMID: 34838273 DOI: 10.1016/j.jval.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 06/02/2021] [Accepted: 06/09/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Early and accurate diagnosis of hip fractures minimizes morbidity and mortality. Although current guidelines favor magnetic resonance imaging (MRI) for the diagnosis of occult hip fractures, a new technology called dual-energy computed tomography (DECT) seems an effective alternative. This article investigates a potentially cost-effective strategy for the diagnosis of occult hip fractures in older adults in Singapore. METHODS A decision tree model was developed to compare costs from a payer's perspective and outcomes in terms of quality-adjusted life-years (QALYs) of different imaging strategies for diagnosing occult hip fracture, comparing MRI with DECT supplementing single-energy computed tomography (SECT) and SECT alone. Model inputs were obtained from local sources where available. Sensitivity analyses are performed to test the robustness of the results. RESULTS The MRI strategy was dominated by the DECT strategy, whereas DECT supplementing SECT provided 0.30 more QALYs at an incremental cost of SGD106.41 with an incremental cost-effectiveness ratio of SGD352.52 per QALY relative to SECT alone. DECT seemed a cost-effective strategy at a willingness-to-pay threshold of SGD50 000 per QALY. CONCLUSION DECT supplementing SECT is a cost-effective imaging strategy to diagnose occult hip fractures among older adults in Singapore and should be included in clinical pathways to expedite timely treatment and considered for reimbursement schemes.
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Affiliation(s)
- Ying Liang Low
- Department of Diagnostic Imaging, National University Hospital, National University Health System, Singapore; Saw Swee Hock School of Public Health, National University of Singapore, Singapore.
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Rogers NB, Karam WN, Kumaravel M, Warner SJ, Gary JL. Dual-Energy CT to Diagnose Occult Femoral Neck Fracture in MRI-Contraindicated Patient: A Case Report. JBJS Case Connect 2021; 11:01709767-202112000-00013. [PMID: 34648465 DOI: 10.2106/jbjs.cc.21.00404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 79-year-old woman presented after a ground level fall with the inability to bear weight on her right hip. Radiographs and computed tomography (CT) imaging were negative for a femoral neck fracture. Her medical comorbidities precluded magnetic resonance imaging (MRI), so dual-energy CT with focused evaluation for bone edema was performed, identifying a femoral neck fracture that was stabilized surgically. CONCLUSION Dual-energy CT with processing for edema can successfully identify nondisplaced femoral neck fractures in MRI-contraindicated patients. This imaging modality could be useful for diagnosing femoral neck stress fractures and ipsilateral femoral neck fractures in patients sustaining high-energy femoral shaft fractures.
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Affiliation(s)
- Nathan B Rogers
- Orthopaedic Surgery Resident, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Wade N Karam
- Orthopaedic Surgery Resident, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Manickam Kumaravel
- Department of Radiology, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Stephen J Warner
- Orthopaedic Trauma Service, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joshua L Gary
- Orthopaedic Trauma Service, Keck Medical Center of University of Southern California, Los Angeles, California
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Abstract
ABSTRACT Hip fractures are considered a significant public health issue, representing a substantial burden on our healthcare system and society. They are one of the leading causes of disability among older adults, especially women. Globally, an estimated 18% of women and 6% of men will be affected by hip fractures at some time in life. Hip fractures are a major cause of long-term disability among older adults and more significant than mortality, as only 60% of patients regain their preinjury level of mobility. This has detrimental effects on quality of life and activities of daily living, imposing a level of dependence that has personal, social, and systemic consequences.
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Affiliation(s)
- Meagan L Barry
- At the time this article was written, Meagan L. Barry was a student in the PA program at the University of Tennessee Health Science Center in Memphis. She now practices at Dallas (Tx.) Orthopaedic Joint Institute. Kristopher R. Maday is an associate professor and program director in the PA program at the University of Tennessee. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Park YC, Song HK, Yang KH. Prevention of Unplanned Surgery Due to Delayed Diagnosis of Occult Ipsilateral Femoral Neck Fractures Associated with Femoral Shaft Fractures: A Study of the CT Capsular Sign with Lipohemarthrosis. J Bone Joint Surg Am 2021; 103:1431-1437. [PMID: 33830965 DOI: 10.2106/jbjs.20.02033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of the present study was to investigate the effectiveness of using the computed tomography (CT) capsular sign with lipohemarthrosis of the hip joint as a selective indicator for preoperative magnetic resonance imaging (MRI) of the hip or prophylactic fixation of the ipsilateral femoral neck for the prevention of unplanned surgery due to delayed diagnosis of occult ipsilateral femoral neck fractures in patients with high-energy femoral shaft fractures. METHODS We evaluated the CT capsular sign with lipohemarthrosis in patients with a high-energy femoral shaft fracture without a preoperative diagnosis of an ipsilateral femoral neck fracture. The CT capsular sign with lipohemarthrosis was considered positive when the side-to-side difference in anterior capsular distension was >1 mm and lipohemarthrosis was seen on soft-tissue-window CT images. A positive CT capsular sign with lipohemarthrosis prompts preoperative hip MRI or prophylactic femoral neck fixation with a reconstruction nail. RESULTS One hundred and fifty-six consecutive patients were included. Eight patients were preoperatively diagnosed with a displaced or hairline ipsilateral femoral neck fracture, whereas the remaining 148 patients showed no ipsilateral femoral neck fracture on radiographs and bone-window CT images. On soft-tissue-window CT images, 29 (19.6%) of the 148 patients had a positive CT capsular sign with lipohemarthrosis. We performed preoperative MRI for 3 patients; in the remaining 26 patients, prophylactic femoral neck fixation was performed with a reconstruction nail. We identified 5 occult ipsilateral femoral neck fractures among the 29 patients with a positive sign: 2 on preoperative MRI scans, 2 on immediate postoperative radiographs, and 1 on radiographs made 6 weeks postoperatively. In 119 patients with a negative sign, no occult ipsilateral femoral neck fracture was identified. All occult ipsilateral femoral neck fractures healed without further displacement of the femoral neck. Consequently, additional unplanned surgery for delayed diagnosis of occult ipsilateral femoral neck fracture was not required. CONCLUSIONS The use of the CT capsular sign with lipohemarthrosis as a selective indicator for preoperative hip MRI or prophylactic femoral neck fixation with a reconstruction nail in patients with high-energy femoral shaft fractures is effective for preventing unplanned surgery due to delayed diagnosis of occult ipsilateral femoral neck fractures. LEVEL OF EVIDENCE Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Young-Chang Park
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.,Department of Orthopedic Surgery, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, South Korea
| | - Hyung-Keun Song
- Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Kyu-Hyun Yang
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Justifying CT prior to MRI in cases of suspected occult hip fracture. A proposed diagnostic protocol. Injury 2021; 52:1429-1433. [PMID: 33039184 DOI: 10.1016/j.injury.2020.09.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/07/2020] [Accepted: 09/29/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Patients with clinical suspicion of hip fracture, but negative radiographs are suspected of having an occult hip fracture (OHF). Different diagnostic modalities are available for investigating OHF and various protocols have been suggested. MRI has the highest sensitivity and specificity, however availability is limited in many institutes. CT is readily accessible in the large majority of hospitals throughout the world but has lower sensitivity and may miss some fractures. In this article we investigate a protocol that balances these issues providing a practical and cost-effective solution. METHODS During a four-year period between 2012 and 2016 a strict diagnostic protocol was followed at our Medical Center for patients suspected of OHF. This MRI selective protocol consisted of CT initially being performed and only when negative for fracture, followed by an MRI. Retrospective analysis of all patients who followed the protocol was performed. The patients were divided into two groups: those diagnosed by CT alone and those diagnosed by MRI after having a negative CT scan. Diagnostic performance, time to diagnosis and the cost of this protocol were evaluated. RESULTS 103 patients were treated under the protocol. In 50 patients (49%) hip fracture was diagnosed by CT alone. In the remaining 53 patients (51%) no definitive diagnosis was reached by CT and MRI was subsequently performed. 12 of these 53 patients (23%) were diagnosed with hip fracture necessitating surgery. In the CT only group mean time from admission to diagnosis was 3 hours, in the CT + MRI group this rose to 40 hours. Cost analysis showed that this protocol was more cost-effective than performing MRI in all patients, saving an estimated 66,805 Euro during the study period. CONCLUSION The clinical challenge of diagnosing OHF can be minimised by implementing a diagnostic protocol. The protocol should take into consideration the diagnostic sensitivity, availability and cost of different imaging modalities. An MRI selective strategy with initial CT scanning is recommended, as it reduces time to diagnosis and lowers overall costs.
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Iatan I, Lee TC, McDonald EG. Tenofovir-induced osteomalacia with hypophosphataemia. BMJ Case Rep 2021; 14:14/5/e240387. [PMID: 34031073 DOI: 10.1136/bcr-2020-240387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Tenofovir disoproxil fumarate (TDF) is an antiretroviral drug widely used as a first-line treatment of hepatitis B virus (HBV) and HIV. Increasing evidence has emerged associating its use with the development of Fanconi syndrome, renal insufficiency and bone disease. We report a case of a 61-year-old woman with a remote history of liver transplant for cirrhosis due to HBV. Over 1 year, the patient had recurrent falls, generalised myalgias and arthralgias, misdiagnosed as fibromyalgia. We discuss a complication of her transplant treatment regimen with the drug TDF leading to a rare but reversible disorder: tenofovir-induced Fanconi osteomalacia with renal phosphate wasting. Though recognised, this rare disorder was initially likely missed due to clinical unfamiliarity with the diagnosis, concomitant psychiatric symptoms and premature diagnostic closure.
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Affiliation(s)
- Iulia Iatan
- General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Todd C Lee
- Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Emily G McDonald
- General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada .,Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
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16
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Law GW, Padki A, Tay KS, Howe TS, Koh JSB, Mak MS, Mohan PC, Chan LP, Png MA. Computed tomography-based diagnosis of occult fragility hip fractures offer shorter waiting times with no inadvertent missed diagnosis. J Orthop Surg (Hong Kong) 2021; 28:2309499020932082. [PMID: 32546057 DOI: 10.1177/2309499020932082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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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Affiliation(s)
- Gin Way Law
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Akshay Padki
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Kae Sian Tay
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Tet Sen Howe
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | | | - May San Mak
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - P Chandra Mohan
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Lai Peng Chan
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Meng Ai Png
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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Zhang T, Wu J, Chen YC, Wu X, Lu L, Mao C. Magnetic Resonance Imaging has Better Accuracy in Detecting New-Onset Rib Fractures as Compared to Computed Tomography. Med Sci Monit 2021; 27:e928463. [PMID: 33424019 PMCID: PMC7812695 DOI: 10.12659/msm.928463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background The aim of this study was to explore the magnetic resonance imaging (MRI) manifestations of new-onset rib fractures and determine the utility of MRI through a comparative study of MRI and computed tomography (CT). Material/Methods Twenty-one patients with mild chest trauma who sought medical care from February 2019 to June 2020 were included in this study. The patients were subjected to CT and MRI scanning within 2 weeks after the trauma, and CT rescanning was scheduled 4–8 weeks later to classify rib fractures and determine the diagnostic accuracy of MRI and CT for new-onset rib fractures. Results Seventy-seven rib fractures were confirmed by CT rescanning, of which 72 (93.51%) were type I fractures and 5 (6.49%) were type II. MRI identified 76 fractures, of which 3 were false positive, with the diagnostic accuracy rate of 91.25% and sensitivity rate of 94.81%. Among them, type I fractures (n=71, 3 were false positive) showed the MRI “sandwich” sign (heterogeneous high-signal shadow within bone marrow of the inner layer, low-signal bony cortex of the middle layer, and high-signal subperiosteal effusion of the outer layer) in T2-weighted fat-suppressed sequences; type II fractures (n=5) displayed intramedullary high-signal intensities and no subperiosteal effusion. Forty-four fractures (all type I) were discovered in the initial CT examination, and the corresponding diagnostic accuracy rate and sensitivity rate were 57.14%, which were lower than that of MRI. Conclusions MRI is highly sensitive for new-onset rib fractures, especially type I, so it is a preferred method for patients with mild chest trauma.
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Affiliation(s)
- Tao Zhang
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Jing Wu
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Yu-Chen Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Xinying Wu
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Lingquan Lu
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Cunnan Mao
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
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Sun EX, Mandell JC, Weaver MJ, Kimbrell V, Harris MB, Khurana B. Clinical utility of a focused hip MRI for assessing suspected hip fracture in the emergency department. Emerg Radiol 2020; 28:317-325. [PMID: 33175269 DOI: 10.1007/s10140-020-01870-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 11/01/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE A focused hip MRI (FHMR) for the detection of radiographically occult hip fractures was implemented in our emergency department (ED) in 2013. The goal of this study was to assess the clinical utility of this protocol. METHODS We retrospectively reviewed radiology reports of 262 unique patients who underwent 263 FHMR (coronal T1, coronal STIR, axial T2 fat saturated) for suspected hip fracture in the ED from October 2013 to March 2020. Electronic medical records were reviewed for the ED course, follow-up imaging, and clinical management within 90 days. RESULTS Seventy-one patients had one or more fractures identified by FHMR: one-third had proximal femoral fractures; two-third had pelvic fractures. Of these 71 patients, 53 (74%) had radiographically occult fractures, including 14 (20%) with occult proximal femoral fractures; 4 patients had fractures occult on CT. Nineteen patients with a suspected fracture on radiography were found to have no fracture on FHMR. Four fractures not reported on FHMR were later seen on follow-up imaging: these included 1 isolated greater trochanter, 1 additional ischial tuberosity, 1 additional superior pubic ramus, and 1 additional sacrum. All four fractures were treated non-operatively. Muscle/tendon injury was the most common type of injury, seen in 50% (130/262) patients with the most commonly torn tendons being the hamstring (44%; 15/34) followed by gluteus medius tendon (18%; 6/34). A full-hip or pelvis MRI was done after FHMR in only 5 patients, primarily for the purpose of better characterizing findings already identified on FHMR (2 for fracture, 2 for tendon injury, 1 for soft tissue metastasis). Only one of these five studies provided new information: ruling out a previously questioned fracture. Clinical management of the vast majority of patients was based solely on findings from the FHMR. CONCLUSIONS FHMR offers reliable identification of radiographically occult hip fractures and muscle/tendon injuries. The protocol is well trusted in guiding patient management in our ED.
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Affiliation(s)
- Ellen X Sun
- Department of Radiology, Division of Emergency Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02215, USA.
| | - Jacob C Mandell
- Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02215, USA
| | - Michael J Weaver
- Department of Orthopedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02215, USA
| | - Vera Kimbrell
- Department of Radiology, Duke University Hospital, 2301 Erwin Rd, Durham, NC, 27710, USA.,Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02215, USA
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Bharti Khurana
- Trauma Imaging Research and Innovation Center, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02215, USA
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Ozimok C, Koff D, Parasu N. Emphasizing the Diagnostic Value of Digital Tomosynthesis in Detecting Hip Fractures. ACTA ACUST UNITED AC 2020; 6:308-314. [PMID: 32879901 PMCID: PMC7442093 DOI: 10.18383/j.tom.2020.00031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Our institution recently implemented the use of digital tomosynthesis (DTS) to workup emergency room patients with suspected hip fractures after initial negative or indeterminate radiographs. Our purpose is to evaluate the diagnostic accuracy of DTS for hip fracture detection. We performed a retrospective review of all DTS studies over a 17-month period (July 2017 to November 2018). The results of the radiographs and DTS were recorded as either positive or negative for fracture based on the radiology report. Our reference standard for a fracture was either confirmation on subsequent CT or MRI from the same visit or documentation of clinical findings supportive of a fracture in the patient’s electronic medical record. For patients with negative DTS who did not undergo subsequent cross-sectional imaging, a missed fracture was excluded if they did not return within 30 days with a confirmed fracture. Among 91 patients, there were 34 confirmed fractures—sites including, 7 femoral necks, 10 pubic rami, and 7 greater trochanters. DTS was positive for fracture in 29 patients; 28 of these fractures were true positives, 6 confirmed on cross-sectional imaging, and 22 confirmed clinically. One false positive was observed in a patient with no clinical evidence of a fracture. Six fractures were not detected by tomosynthesis but confirmed on CT/MRI. The sensitivity and specificity of DTS are 82% and 98%, respectively, compared to that of radiographs alone at 47% and 96%, respectively. DTS is a promising adjunct to radiographs for hip fracture detection in an emergency department.
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Affiliation(s)
- Cory Ozimok
- Department of Radiology, Faculty of Health Sciences, McMaster University, Hamilton, ON
| | - David Koff
- McMaster University Medical Centre; and Department of Diagnostic Imaging, Juravinski Cancer Center, Hamilton Health Sciences, Hamilton, ON
| | - Naveen Parasu
- McMaster University Medical Centre; and Department of Diagnostic Imaging, Juravinski Cancer Center, Hamilton Health Sciences, Hamilton, ON
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Haims AH, Wang A, Yoo BJ, Porrino J. Negative predictive value of CT for occult fractures of the hip and pelvis with imaging follow-up. Emerg Radiol 2020; 28:259-264. [PMID: 32844321 DOI: 10.1007/s10140-020-01834-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/30/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To determine the negative predictive value of multidetector CT for radiographically occult fracture of the hip or pelvis in an elderly population presenting to the emergency department. METHODS Two hundred thirty-seven elderly patients with suspected fracture were identified over a 5-year period with negative radiographs acquired in the emergency department followed by an index CT of the hip/pelvis within 24 h. There were 81 cases with a negative index CT, as determined by 2 musculoskeletal radiologists, and with some form of imaging follow-up (MRI, CT, or x-ray) performed within 18 months of the index CT. Follow-up imaging was reviewed by 2 musculoskeletal radiologists for the presence of fracture to determine the performance of the index CT. The electronic medical record was used to exclude the possibility of intervening trauma between the time of the index CT and follow-up imaging. RESULTS There were 39 cases with follow-up imaging performed within 6 weeks of the negative index CT, and 42 with follow-up imaging within 6 weeks to 18 months of the negative index CT. Eight of 81 patients demonstrated a fracture on follow-up imaging, with 3 of 8 involving the femoral neck or intertrochanteric femur. The negative predictive value of the index CT for the detection of a radiographically occult hip or pelvic fracture was 90.1%. If considering only surgically relevant fractures (femoral neck and intertrochanteric fractures), the negative predictive value improved to 96.3%. CONCLUSION Computed tomography for occult hip fractures has a high negative predictive value but there are cases not detected with surgical implications.
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Affiliation(s)
- Andrew H Haims
- Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA.
| | - Annie Wang
- Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Brad J Yoo
- Orthopedics and Rehabilitation, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
| | - Jack Porrino
- Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06520, USA
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Haj-Mirzaian A, Eng J, Khorasani R, Raja AS, Levin AS, Smith SE, Johnson PT, Demehri S. Use of Advanced Imaging for Radiographically Occult Hip Fracture in Elderly Patients: A Systematic Review and Meta-Analysis. Radiology 2020; 296:521-531. [PMID: 32633673 DOI: 10.1148/radiol.2020192167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Arya Haj-Mirzaian
- From the Russell H. Morgan Department of Radiology and Radiological Science, (A.H., J.E., P.T.J., S.D.) Department of Orthopaedic Surgery (A.S.L.), and High Value Practice Academic Alliance (A.H., A.S.R., P.T.J., S.D.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3140D, Baltimore, MD 21287; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (R.K., S.E.S.); Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (A.S.R.); and Library of Evidence, Harvard Medical School, Boston, Mass (R.K., A.S.R.)
| | - John Eng
- From the Russell H. Morgan Department of Radiology and Radiological Science, (A.H., J.E., P.T.J., S.D.) Department of Orthopaedic Surgery (A.S.L.), and High Value Practice Academic Alliance (A.H., A.S.R., P.T.J., S.D.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3140D, Baltimore, MD 21287; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (R.K., S.E.S.); Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (A.S.R.); and Library of Evidence, Harvard Medical School, Boston, Mass (R.K., A.S.R.)
| | - Ramin Khorasani
- From the Russell H. Morgan Department of Radiology and Radiological Science, (A.H., J.E., P.T.J., S.D.) Department of Orthopaedic Surgery (A.S.L.), and High Value Practice Academic Alliance (A.H., A.S.R., P.T.J., S.D.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3140D, Baltimore, MD 21287; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (R.K., S.E.S.); Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (A.S.R.); and Library of Evidence, Harvard Medical School, Boston, Mass (R.K., A.S.R.)
| | - Ali S Raja
- From the Russell H. Morgan Department of Radiology and Radiological Science, (A.H., J.E., P.T.J., S.D.) Department of Orthopaedic Surgery (A.S.L.), and High Value Practice Academic Alliance (A.H., A.S.R., P.T.J., S.D.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3140D, Baltimore, MD 21287; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (R.K., S.E.S.); Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (A.S.R.); and Library of Evidence, Harvard Medical School, Boston, Mass (R.K., A.S.R.)
| | - Adam S Levin
- From the Russell H. Morgan Department of Radiology and Radiological Science, (A.H., J.E., P.T.J., S.D.) Department of Orthopaedic Surgery (A.S.L.), and High Value Practice Academic Alliance (A.H., A.S.R., P.T.J., S.D.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3140D, Baltimore, MD 21287; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (R.K., S.E.S.); Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (A.S.R.); and Library of Evidence, Harvard Medical School, Boston, Mass (R.K., A.S.R.)
| | - Stacy E Smith
- From the Russell H. Morgan Department of Radiology and Radiological Science, (A.H., J.E., P.T.J., S.D.) Department of Orthopaedic Surgery (A.S.L.), and High Value Practice Academic Alliance (A.H., A.S.R., P.T.J., S.D.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3140D, Baltimore, MD 21287; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (R.K., S.E.S.); Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (A.S.R.); and Library of Evidence, Harvard Medical School, Boston, Mass (R.K., A.S.R.)
| | - Pamela T Johnson
- From the Russell H. Morgan Department of Radiology and Radiological Science, (A.H., J.E., P.T.J., S.D.) Department of Orthopaedic Surgery (A.S.L.), and High Value Practice Academic Alliance (A.H., A.S.R., P.T.J., S.D.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3140D, Baltimore, MD 21287; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (R.K., S.E.S.); Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (A.S.R.); and Library of Evidence, Harvard Medical School, Boston, Mass (R.K., A.S.R.)
| | - Shadpour Demehri
- From the Russell H. Morgan Department of Radiology and Radiological Science, (A.H., J.E., P.T.J., S.D.) Department of Orthopaedic Surgery (A.S.L.), and High Value Practice Academic Alliance (A.H., A.S.R., P.T.J., S.D.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3140D, Baltimore, MD 21287; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (R.K., S.E.S.); Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (A.S.R.); and Library of Evidence, Harvard Medical School, Boston, Mass (R.K., A.S.R.)
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Abstract
PURPOSE OF REVIEW This review discusses imaging modalities for fracture repair assessment, with an emphasis on pragmatic clinical and translational use, best practices for implementation, and challenges and opportunities for continuing research. RECENT FINDINGS Semiquantitative radiographic union scoring remains the clinical gold standard, but has questionable reliability as a surrogate indicator of structural bone healing, particularly in early-stage, complex, or compromised healing scenarios. Alternatively, computed tomography (CT) scanning enables quantitative assessment of callus morphometry and mechanics through the use of patient-specific finite-element models. Dual-energy X-ray absorptiometry (DXA) scanning and radiostereometric analysis (RSA) are also quantitative, but technically challenging. Nonionizing magnetic resonance (MR) and ultrasound imaging are of high interest, but require development to enable quantification of 3D mineralized structures. Emerging image-based methods for quantitative assessment of bone healing may transform clinical research design by displacing binary outcomes classification (union/nonunion) and ultimately enhance clinical care by enabling early nonunion detection.
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Affiliation(s)
- Peter Schwarzenberg
- Department of Mechanical Engineering & Mechanics, Lehigh University, Bethlehem, PA, USA
| | - Salim Darwiche
- Musculoskeletal Research Unit (MSRU), Vetsuisse Faculty, University of Zürich, Zürich, Switzerland
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zürich, Zürich, Switzerland
| | - Richard S Yoon
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Jersey City Medical Center - RWJBarnabas Health, Jersey City, NJ, USA
| | - Hannah L Dailey
- Department of Mechanical Engineering & Mechanics, Lehigh University, Bethlehem, PA, USA.
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Radiologic discrepancies in diagnosis of fractures in a Dutch teaching emergency department: a retrospective analysis. Scand J Trauma Resusc Emerg Med 2020; 28:38. [PMID: 32404206 PMCID: PMC7222339 DOI: 10.1186/s13049-020-00727-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 04/17/2020] [Indexed: 11/10/2022] Open
Abstract
Background Missed fractures in the emergency department (ED) are common and may lead to patient morbidity. Aim To determine the rate and nature of radiographic discrepancies between ED treating physicians, radiologists and trauma/orthopaedic surgeons and the clinical consequences of delayed diagnosis. A secondary outcome measurement is the timeframe in which most fractures were missed. Methods A single-centre retrospective analysis of all missed fractures in a general teaching hospital from 2012 to 2017 was performed. Data regarding missed fractures were provided by the hospital’s complication list and related database. Additional data were retrieved from the electronic medical records as required for the study. Results A total of 25,957 fractures were treated at our ED. Initially, 289 fractures were missed by ED treating physicians (1.1%). The most frequently missed fractures were the elbow (28.6%) and wrist (20.8%) in children, the foot (17.2%) in adults and the pelvis and hip (37.3%) in elderly patients. Patients required surgery in 9.3% of missed fractures, received immobilization by a cast or brace in 45.7%, had no treatment alterations during the first week in 38.1%. Follow-up data were lacking for 6.9% of cases. 49% of all missed fractures took place between 4 PM and 9 PM. There is a discrepancy in percentages of correctly diagnosed fractures and missed fractures between 5 PM and 3 AM. Conclusion Adequate training of ED treating physicians in radiographic interpretation is essential in order to increase diagnostic accuracy. A daily multidisciplinary radiology meeting is very effective in detecting missed fractures.
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Kutaiba N, Lamanna A, Malara F, Yap LP. Use of computed tomography and magnetic resonance imaging for occult neck of femur fractures: A single-centre study. Emerg Med Australas 2020; 32:980-985. [PMID: 32358927 DOI: 10.1111/1742-6723.13524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 04/07/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Neck of femur (NOF) fractures are common and serious injuries in the elderly. When a NOF fracture is suspected but is not clearly visible on radiographs, guidelines recommend magnetic resonance imaging (MRI), or computed tomography (CT) if MRI is not available/contraindicated. The aim of our study was to review the use of CT and subsequent MRI for suspected NOF fractures in patients with negative or equivocal radiographs. METHODS A retrospective review of adult patients with negative or equivocal plain radiographs with suspected NOF fractures presenting between 1 July 2015 and 30 June 2017 was performed. Review of CT and subsequent MRI studies was performed with documentation of reported findings, time intervals from plain radiographs to CT and MRI and final outcomes. RESULTS A total of 184 CT studies in 181 patients were reviewed; median age was 82 years (interquartile range 71-89 years) with 110 (60.8%) female patients. CT reported 20 occult fractures; all proceeded to surgery. MRI was performed in 23 patients and revealed additional four NOF fractures missed by CT. An additional fifth fracture missed by CT was confirmed by follow-up radiographs. Median time was approximately 4 h from radiographs to CT and approximately 56 h from radiographs to MRI. CONCLUSION Access to CT for evaluation of suspected occult NOF fractures is much quicker compared to MRI. When CT results are negative with on-going clinical suspicion of an occult fracture, MRI should be performed in a time efficient manner.
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Affiliation(s)
- Numan Kutaiba
- Radiology Department, Austin Health, Melbourne, Victoria, Australia
| | - Anthony Lamanna
- Radiology Department, Austin Health, Melbourne, Victoria, Australia
| | - Frank Malara
- Radiology Department, Austin Health, Melbourne, Victoria, Australia
| | - Lee-Pheng Yap
- Radiology Department, Austin Health, Melbourne, Victoria, Australia
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Diagnostic Performance of CT for Occult Proximal Femoral Fractures: More Details, More Significance. AJR Am J Roentgenol 2020; 214:W74. [PMID: 32196373 DOI: 10.2214/ajr.19.22295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Reply to “Diagnostic Performance of CT for Occult Proximal Femoral Fractures: More Details, More Significance”. AJR Am J Roentgenol 2020; 214:W75. [DOI: 10.2214/ajr.19.22476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Park YC, Um KS, Hong SP, Oh CW, Kim S, Yang KH. Preoperative "Computed tomography capsular sign" for the detection of occult ipsilateral femoral neck fractures associated with femoral shaft fractures. Injury 2020; 51:1051-1056. [PMID: 32093939 DOI: 10.1016/j.injury.2020.02.067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/12/2020] [Accepted: 02/15/2020] [Indexed: 02/02/2023]
Abstract
AIM We scrutinised the computed tomography (CT) capsular sign, which refers to the anterior capsular distension of the hip, to determine whether we can use it as an additional clue for detecting occult ipsilateral femoral neck fracture (IFNF) before operation. PATIENTS AND METHODS We retrospectively examined 79 patients who suffered high-energy femoral shaft fracture and were evaluated with preoperative CT for occult IFNF. The occult IFNF was defined as a fracture that was not diagnosed confirmatively during preoperative evaluation. Thirteen patients were included in the occult IFNF group and 66 were included in the femoral neck intact group. A side-to-side difference of more than 1 mm of capsular distension was considered a positive CT capsular sign. RESULTS Among 13 patients in the occult IFNF group, 6 had a hairline fracture (bony window images) and 12 had a positive CT capsular sign (soft tissue window images) on preoperative CT scans. The presence of IFNF was more significantly associated with the CT capsular sign than with the hairline fracture (p = 0.031). Among the 66 patients in the femoral neck intact group, the CT capsular sign was false positive in 4. CONCLUSION The CT capsular sign can be used to detect the presence of occult IFNF in high-energy trauma patients with femoral shaft fractures. During the preoperative evaluation of IFNF, surgeons must pay extra attention to the presence of occult IFNF when the CT capsular sign is positive.
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Affiliation(s)
- Young-Chang Park
- Department of Orthopedic Surgery, International ST. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Republic of Korea
| | - Kyu-Sub Um
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-Gu, 135-720 Seoul, Republic of Korea
| | - Seung-Pyo Hong
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-Gu, 135-720 Seoul, Republic of Korea
| | - Chang-Wug Oh
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, 130 Dongdeok-ro, Jung-gu, Daegu, Republic of Korea
| | - Sungjun Kim
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-Gu, Seoul, Republic of Korea
| | - Kyu-Hyun Yang
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-Gu, 135-720 Seoul, Republic of Korea.
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Imaging Considerations in Musculoskeletal Trauma. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2019.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Diagnostic Performance of CT for Occult Proximal Femoral Fractures: A Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2019; 213:1324-1330. [DOI: 10.2214/ajr.19.21510] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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30
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Magidson PD, Thoburn AK, Hogan TM. Emergency Orthogeriatrics: Concepts and Therapeutic Considerations for the Geriatric Patient. Emerg Med Clin North Am 2019; 38:15-29. [PMID: 31757248 DOI: 10.1016/j.emc.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Appropriate recognition of the physiologic, psychological, and clinical differences among geriatric patients, with respect to orthopedic injury and disease, is paramount for all emergency medicine providers to ensure they are providing high-value care for this vulnerable population.
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Affiliation(s)
- Phillip D Magidson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, A1 East Suite 150, Baltimore, MD 21224, USA.
| | - Allison K Thoburn
- Department of Medicine, Section of Geriatrics and Palliative Medicine, University of Chicago Medicine, 5841 South Maryland Avenue, MC 6098, Chicago, IL 60637, USA
| | - Teresita M Hogan
- Department of Medicine, Division of Emergency Medicine, University of Chicago School of Medicine, 5841 South Maryland Avenue, MC 6098, Chicago, IL 60637, USA
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Jang SW, Chung BM, Kim WT, Gil JR. Nondisplaced fractures on hip CT: added value of dual-energy CT virtual non-calcium imaging for detection of bone marrow edema using visual and quantitative analyses. Acta Radiol 2019; 60:1465-1473. [PMID: 30818978 DOI: 10.1177/0284185119831690] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Seong Won Jang
- Department of Radiology, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Bo Mi Chung
- Department of Radiology, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Wan Tae Kim
- Department of Radiology, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Jea Ryung Gil
- Department of Radiology, Veterans Health Service Medical Center, Seoul, Republic of Korea
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Lanotte SJ, Larbi A, Michoux N, Baron MP, Hamard A, Mourad C, Malghem J, Cyteval C, Vande Berg BC. Value of CT to detect radiographically occult injuries of the proximal femur in elderly patients after low-energy trauma: determination of non-inferiority margins of CT in comparison with MRI. Eur Radiol 2019; 30:1113-1126. [PMID: 31650264 DOI: 10.1007/s00330-019-06387-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 07/05/2019] [Accepted: 07/22/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE To determine the margins of non-inferiority of the sensitivity of CT and the sample size needed to test the non-inferiority of CT in comparison with MRI. MATERIALS AND METHODS During a 2-year period, elderly patients with suspected radiographically occult post-traumatic bone injuries were investigated by CT and MRI in two institutions. Four radiologists analyzed separately the CT and MRI examinations to detect post-traumatic femoral injuries. Their sensitivities at CT (SeCT) and MRI (SeMRI) were calculated with the reference being a best valuable comparator (consensus reading of the MRI and clinical follow-up). ROC analysis followed by an exact test (Newcombe's approach) was performed to assess the 95% confidence interval (CI) for the difference SeCT-SeMRI for each reader. A sample size calculation was performed based on our observed results by using a one-sided McNemar's test. RESULTS Twenty-nine out of 102 study participants had a post-traumatic femoral injury. SeCT ranged between 83 and 93% and SeMRI ranged between 97 and 100%. The 95% CIs for (SeCT-SeMRI) were [- 5.3%, + 0.8%], (pR1 = 0.1250), [- 4.5%; + 1.2%] (pR2 = 0.2188), [- 3.4%; + 1.1%] (pR3 = 0.2500) to [- 3.8%; + 1.6%] (pR4 = 0.3750) according to readers, with a lowest limit for 95% CIs superior to a non-inferiority margin of (- 6%) for all readers. A population of 440 patients should be analyzed to test the non-inferiority of CT in comparison with MRI. CONCLUSION CT and MRI are sensitive for the detection of radiographically occult femoral fractures in elderly patients after low-energy trauma. The choice between both these modalities is a compromise between the most available and the most sensitive technique. KEY POINTS • The sensitivity of four separate readers to detect radiographically occult post-traumatic femoral injuries in elderly patients after low-energy trauma ranged between 83 and 93% at CT and between 97 and 100% at MRI according to a best valuable comparator including MRI and clinical follow-up. • CT is a valuable alternative method to MRI for the detection of post-traumatic femoral injuries in elderlies after low-energy trauma if a 6% loss in sensitivity can be accepted in comparison with MRI. • The choice between CT and MRI is a compromise between the most available and the most sensitive technique.
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Affiliation(s)
- Solenne J Lanotte
- Department of Radiology, Institut de Recherche expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain (UCLouvain), 1200, Brussels, Belgium
| | - Ahmed Larbi
- Department of Radiology, Faculté de Médecine de Montpellier/Nîmes, Hôpital Lapeyronie, 34000, Montpellier, France
| | - Nicolas Michoux
- Department of Radiology, Institut de Recherche expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain (UCLouvain), 1200, Brussels, Belgium
| | - Marie-Pierre Baron
- Department of Radiology, Faculté de Médecine de Montpellier/Nîmes, Hôpital Lapeyronie, 34000, Montpellier, France
| | - Aymeric Hamard
- Department of Radiology, Faculté de Médecine de Montpellier/Nîmes, Hôpital Lapeyronie, 34000, Montpellier, France
| | - Charbel Mourad
- Department of Radiology, Institut de Recherche expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain (UCLouvain), 1200, Brussels, Belgium
| | - Jacques Malghem
- Department of Radiology, Institut de Recherche expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain (UCLouvain), 1200, Brussels, Belgium
| | - Catherine Cyteval
- Department of Radiology, Faculté de Médecine de Montpellier/Nîmes, Hôpital Lapeyronie, 34000, Montpellier, France
| | - Bruno C Vande Berg
- Department of Radiology, Institut de Recherche expérimentale et Clinique (IREC), Cliniques Universitaires Saint Luc, Université Catholique de Louvain (UCLouvain), 1200, Brussels, Belgium.
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Multi-detector CT for suspected hip fragility fractures: A diagnostic test accuracy systematic review and meta-analysis. Emerg Radiol 2019; 26:549-556. [PMID: 31209592 DOI: 10.1007/s10140-019-01696-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 05/15/2019] [Indexed: 12/19/2022]
Abstract
To perform a systematic review (SR) and meta-analysis to determine the diagnostic test accuracy (DTA) of Multi-Detector Computed Tomography (MDCT) for detecting proximal femoral (hip) fragility fractures in patients with a negative initial radiograph. MEDLINE and EMBASE were searched to identify relevant studies published between January 2000 and May 2018. Articles underwent title and abstract screening followed by full-text screening. Study inclusion criteria are patients with suspected hip fracture, negative initial radiograph, MDCT as the index test, magnetic resonance imaging (MRI) or clinical follow-up as the reference standard, and DTA measure as the outcome. Demographic, methodologic, and study outcome data were extracted. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. DTA metrics were pooled using bivariate random-effects meta-analysis. From an initial 1385 studies, four studies reporting on 418 patients (174 with hip fractures) were included. Pooled summary statistics included the following: sensitivity (87%; 95% confidence interval [CI] 79-93), specificity (98%; 95% CI 95-99), and the area under the summary receiver operating characteristic (ROC) curve (0.972). MDCT has a high specificity for detecting hip fragility fractures, comparable to MRI, but a lower sensitivity. Local institutional factors may play a role in whether a patient receives MDCT or MRI, as imaging should not be delayed. If there is ongoing concern for fracture in a patient with a negative MDCT, MRI should be performed. Cautious interpretation of the results is warranted given the risk of bias and small sample size.
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ACR Appropriateness Criteria® Acute Hip Pain-Suspected Fracture. J Am Coll Radiol 2019; 16:S18-S25. [DOI: 10.1016/j.jacr.2019.02.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 11/23/2022]
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Noh J, Lee KH, Jung S, Hwang S. The Frequency of Occult Intertrochanteric Fractures among Individuals with Isolated Greater Trochanteric Fractures. Hip Pelvis 2019; 31:23-32. [PMID: 30899712 PMCID: PMC6414406 DOI: 10.5371/hp.2019.31.1.23] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/17/2018] [Accepted: 12/20/2018] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Jongho Noh
- Department of Orthopedic Surgery, The Catholic University of Korea, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Kee Haeng Lee
- Department of Orthopedic Surgery, The Catholic University of Korea, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Sehoon Jung
- Department of Orthopedic Surgery, The Catholic University of Korea, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Sunwook Hwang
- Department of Orthopedic Surgery, The Catholic University of Korea, Bucheon St. Mary's Hospital, Bucheon, Korea
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Heynen B, Tamigneaux C, Pasoglou V, Malghem J, Vande Berg B, Kirchgesner T. MRI detection of radiographically occult fractures of the hip and pelvis in the elderly: Comparison of T2-weighted Dixon sequence with T1-weighted and STIR sequences. Diagn Interv Imaging 2019; 100:169-175. [DOI: 10.1016/j.diii.2018.11.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 11/22/2018] [Accepted: 11/23/2018] [Indexed: 11/25/2022]
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Williams J, Allen F, Kedrzycki M, Shenava Y, Gupta R. Use of Multislice CT for Investigation of Occult Geriatric Hip Fractures and Impact on Timing of Surgery. Geriatr Orthop Surg Rehabil 2019; 10:2151459318821214. [PMID: 30719399 PMCID: PMC6348569 DOI: 10.1177/2151459318821214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 11/26/2018] [Indexed: 11/20/2022] Open
Abstract
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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Affiliation(s)
- John Williams
- Department of Trauma & Orthopaedics, Queen Elizabeth Hospital, London, United Kingdom
| | - Felix Allen
- Department of Trauma & Orthopaedics, Queen Elizabeth Hospital, London, United Kingdom
| | - Marta Kedrzycki
- Department of Trauma & Orthopaedics, Queen Elizabeth Hospital, London, United Kingdom
| | - Yathish Shenava
- Department of Trauma & Orthopaedics, Queen Elizabeth Hospital, London, United Kingdom
| | - Renu Gupta
- Department of Radiology, Queen Elizabeth Hospital, London, United Kingdom
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Diagnostic accuracy of an abbreviated MRI protocol for detecting radiographically occult hip and pelvis fractures in the elderly. Skeletal Radiol 2019; 48:103-108. [PMID: 29915937 DOI: 10.1007/s00256-018-3004-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/23/2018] [Accepted: 06/05/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the diagnostic accuracy of an abbreviated, two-sequence MRI protocol using limited pulse sequences for the detection of radiographically occult hip and pelvis fractures in the elderly compared to the complete MRI examination. MATERIALS AND METHODS One hundred and eleven consecutive emergency department patients age 65 or older who had undergone MRI to evaluate for clinically suspected hip fracture after negative radiographs were included in the study. The large field-of-view coronal T1 and STIR sequences were isolated from the complete six-sequence MRI protocol and reviewed independently in a blinded fashion by two musculoskeletal fellowship-trained radiologists who recorded presence or absence of fractures of the proximal femora or pelvis, fracture type, and presence or absence of soft tissue injury. Test accuracy was calculated with 95% confidence intervals and accuracy of fracture classification for the abbreviated protocol was compared to that made on the basis of the full exam. RESULTS For proximal femoral fractures, the abbreviated protocol had a pooled sensitivity and specificity for the two readers of 100 and 97%, respectively. For pelvic fractures, sensitivity was 92% and specificity was 98%. The kappa coefficient for fracture classification was 0.90 for reader 1 and 0.88 for reader 2, indicating excellent agreement for both readers in fracture classification compared to the classification made based on the complete MRI protocol. CONCLUSIONS An abbreviated MRI protocol that includes only coronal T1 and STIR sequences maintains high sensitivity and specificity for hip and pelvis fracture detection and fracture classification.
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Ho SWL, Thwin L, Kwek EBK. Clinical characteristics and short to mid term functional outcomes of surgically treated occult hip fractures in the elderly. Injury 2018; 49:2216-2220. [PMID: 30360929 DOI: 10.1016/j.injury.2018.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 09/23/2018] [Accepted: 10/13/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Occult hip fractures in the elderly are challenging to diagnose and often result in surgical delays which may worsen outcomes. However, the minimally displaced nature of these fractures may conversely lead to better outcomes. The aim of this study was to determine if surgically treated occult hip fractures have better short to mid term functional outcomes when compared to non-occult fractures. The secondary aim was to determine if there are any differences in clinical characteristics of patients who present with occult hip fractures. METHODS This was a retrospective cohort study of all elderly patients aged 65 years and above who presented with hip fractures in a single institution from January 2012 to December 2013. Elderly patients who presented with hip fractures were enrolled into an Ortho-geriatric carepath and were eligible for recruitment. The exclusion criteria included patients with pathological fractures and multiple injuries. Demographic and pre-injury variables were collected. The functional outcome measurement was the Modified Barthel's Index (MBI). Patients were divided into non-occult hip fractures (Group 1) and occult hip fractures (Group 2). RESULTS A total of 1017 patients were admitted during this period into the hip fracture carepath, of which 49 (4.8%) were diagnosed to have occult hip fractures. There was no significant difference between the demographics, Charlson co-morbidity index, abbreviated mental test scores or pre-morbid patient dependence between the groups. There was a significant delay to surgery for occult hip fractures when compared to non-occult fractures. (p = 0.03) Subgroup analysis showed that pre-morbidly, patients with occult inter-trochanteric fractures were significantly more independent than patients with non-occult inter-trochanteric fractures. (p = 0.03) There was no significant difference between the length of stay, surgical complications and 1-year mortality between the 2 groups. Occult inter-trochanteric fractures had better MBI scores at all time points when compared to non-occult inter-trochanteric fractures. CONCLUSIONS Despite the significant delay to surgical intervention for patients with occult hip fractures, the short to mid term functional outcomes for this group of patients are comparable to surgically treated non-occult hip fractures. There are no distinctive clinical characteristics of elderly patients who are more likely to suffer occult hip fractures.
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Affiliation(s)
- Sean W L Ho
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore.
| | - Lynn Thwin
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore.
| | - Ernest B K Kwek
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore.
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Abstract
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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Yumoto T, Joko R, Yamakawa Y, Yamada T, Naito H, Nakao A. Subperiosteal Hematoma of the Iliac Bone: An Unusual Cause of Acute Hip Pain after a Fall. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:1083-1086. [PMID: 30206200 PMCID: PMC6144983 DOI: 10.12659/ajcr.910010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 07/02/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Subperiosteal hematoma (SPH) of the iliac bone is an extremely uncommon clinical entity that occurs mostly in young patients with a history of a recent fall or sports-related injury. Patients usually complain of severe hip pain after a fall, mimicking femoral neck fracture. CASE REPORT An 18-year-old female was transported to our hospital complaining of pain in her left hip after falling on her buttocks while engaging in martial arts. Ultrasound of her left iliac region revealed a subperiosteal mass on the internal aspect of the iliac bone lifting the iliac muscle. SPH of the iliac bone was suspected, which was also evident on pelvis and hip magnetic resonance imaging. Repetitive ultrasound did not reveal hematoma expansion. She was discharged from the hospital the next day without femoral neuropathy. CONCLUSIONS Physicians should be aware of our report, which highlights a patient with the rare clinical condition of SPH of the iliac bone occurring immediately after a fall. The differential diagnosis of acute hip pain, which mimics femoral neck fracture, should be considered in young patients. Ultrasound of the iliac region may be useful in detection and further management of SPH of the iliac bone.
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Affiliation(s)
- Tetsuya Yumoto
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama City, Okayama, Japan
| | - Ryoji Joko
- Department of Orthopedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama City, Okayama, Japan
| | - Yasuaki Yamakawa
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama City, Okayama, Japan
| | - Taihei Yamada
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama City, Okayama, Japan
| | - Hiromichi Naito
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama City, Okayama, Japan
| | - Atsunori Nakao
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, Okayama City, Okayama, Japan
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Clinical applications of a computed tomography color “marrow mapping” algorithm to increase conspicuity of nondisplaced trabecular fractures. Emerg Radiol 2018; 26:59-66. [DOI: 10.1007/s10140-018-1631-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 08/01/2018] [Indexed: 01/14/2023]
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Moon NH, Shin WC, Do MU, Woo SH, Son SM, Suh KT. Diagnostic strategy for elderly patients with isolated greater trochanter fractures on plain radiographs. BMC Musculoskelet Disord 2018; 19:256. [PMID: 30045720 PMCID: PMC6060539 DOI: 10.1186/s12891-018-2193-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 07/13/2018] [Indexed: 11/30/2022] Open
Abstract
Background Isolated greater trochanter (GT) fractures are relatively rare and few studies have assessed the appropriate diagnostic and therapeutic strategies for these fractures. When initial plain radiographs show an isolated GT fracture, underestimation of occult intertrochanteric extension may result in displacement of a previously non-displaced fracture. This study examined the clinical results and value of different diagnostic strategies in elderly patients with isolated GT fractures on plain radiographs. Methods Between January 2010 and January 2015, 30 patients with initial plain radiographs showing isolated GT fractures were examined using MRI, bone scanning and/or CT for suspected occult intertrochanteric extension. We assessed the sensitivity, specificity, and positive and negative predictive value of each test. In addition, we noted the location of the fracture or soft-tissue injury on MRI in addition to treatment results. Results All 30 patients had osteoporosis and fractures caused by minor trauma. MRI revealed isolated GT fractures in nine patients and occult intertrochanteric fractures in 21 patients. Using the MRI-based diagnosis as a reference, the results showed that plain radiographs, bone scans, and CT scans can be used for supplementary examination but they are not appropriate as confirmatory tests for these fractures. However, in patients with both isolated GT fractures seen on plain radiographs and increased uptake in only the GT area on bone scans, MRI revealed isolated GT fractures. The fractures were treated surgically in 20 patients and conservatively in 10 patients with satisfactory clinical results. Conclusions We confirmed that MRI-based examination is useful in all symptomatic elderly patients whose plain radiographic findings reveal isolated GT fractures. However, we suggest that there is a need to establish a diagnostic strategy through increased understanding of the available diagnostic methods. We believe that surgical treatment should be considered in patients with occult intertrochanteric fractures that are detected on MRI.
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Affiliation(s)
- Nam Hoon Moon
- Department of Orthopedic Surgery, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Won Chul Shin
- Department of Orthopedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan, Gyeongsangnam-do, 626-770, Republic of Korea.
| | - Min Uk Do
- Department of Orthopedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan, Gyeongsangnam-do, 626-770, Republic of Korea
| | - Seung Hun Woo
- Department of Orthopedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan, Gyeongsangnam-do, 626-770, Republic of Korea
| | - Seung Min Son
- Department of Orthopedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan, Gyeongsangnam-do, 626-770, Republic of Korea
| | - Kuen Tak Suh
- Department of Orthopedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan, Gyeongsangnam-do, 626-770, Republic of Korea
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Smeets SJM, Vening W, Winkes MB, Kuijt GP, Slooter GD, van Eerten PV. The patellar pubic percussion test: a simple bedside tool for suspected occult hip fractures. INTERNATIONAL ORTHOPAEDICS 2018; 42:2521-2524. [PMID: 30019126 DOI: 10.1007/s00264-018-4036-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 06/12/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE Patellar finger tapping produces a typical sound that can be detected by a stethoscope positioned on the pubic bone (patellar pubic percussion test (PPPT)). Characteristics of this sound are determined by continuity of bone between patella and pelvis. We hypothesized that a PPPT was able to detect overt hip fractures and occult hip fractures that may not be determined by a standard radiological examination. METHODS Two independent observers performed a PPPT in patients with a suspected hip or pelvic fracture, just before a conventional radiograph (X-ray) was performed. The PPPT test was scored as negative (similar to contralateral side) or positive (different). Patients with a positive PPPT but with a negative X-ray underwent an additional CT scan. RESULTS One hundred and ninety-one patients with suspected hip or pelvic fracture were included. A total of 161 patients (84%) were diagnosed with a fracture (hip, n = 142; pelvic, n = 19). An 85% sensitivity, a 70% specificity, a 0.94 positive predictive value, and a 0.47 negative predictive value of the PTTT were calculated. The inter-observer reliability (kappa) was 0.7. Eleven CT scans as indicated by a mismatch between PPPT (positive) and X-ray (no fracture) identified eight fractures (73%). A multivariate analysis demonstrated that a painful passive movement and the PPPT predicted a hip fracture. CONCLUSION The PPPT is a simple bedside diagnostic tool that is sensitive in detecting clinically straight forward hip fractures as well as occult hip fractures. The PPPT can support decision-making for additional radiological examinations in case of potential occult pelvis or hip fractures.
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Affiliation(s)
| | - Wouter Vening
- Rijnstate, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
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Mandell JC, Rocha TC, Duran-Mendicuti MA, Miskin NP, Shi J, Khurana B. Color postprocessing of conventional CT images: preliminary results in assessment of nondisplaced proximal femoral fractures. Emerg Radiol 2018; 25:639-645. [DOI: 10.1007/s10140-018-1626-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 07/06/2018] [Indexed: 11/28/2022]
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Grammatopoulos G, McCarthy C, Carli A, Gofton W. Occult fractures around the hip. Br J Hosp Med (Lond) 2018; 79:C60-C64. [PMID: 29620975 DOI: 10.12968/hmed.2018.79.4.c60] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- George Grammatopoulos
- Consultant Trauma and Orthopaedic Surgeon, Department of Trauma and Orthopaedics, University College London Hospitals NHS Trust, London NW1 2BU
| | - Catherine McCarthy
- Consultant Musculoskeletal Radiologist, Department of Musculoskeletal Radiology, Oxford University Hospitals NHS Foundation Trust Nuffield Orthopaedic Centre, University of Oxford, Oxford
| | - Alberto Carli
- Consultant Orthopaedic and Trauma Surgeon, Department of Trauma and Orthopaedics, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Wade Gofton
- Consultant Orthopaedic and Trauma Surgeon, Department of Trauma and Orthopaedics, The Ottawa Hospital, Ottawa, Ontario, Canada
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Mandell JC, Weaver MJ, Khurana B. Computed tomography for occult fractures of the proximal femur, pelvis, and sacrum in clinical practice: single institution, dual-site experience. Emerg Radiol 2018; 25:265-273. [DOI: 10.1007/s10140-018-1580-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 01/03/2018] [Indexed: 12/17/2022]
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Ronga M, Bonzini D, Valoroso M, La Barbera G, Tamini J, Cherubino M, Cherubino P. Blood loss in trochanteric fractures: multivariate analysis comparing dynamic hip screw and Gamma nail. Injury 2017; 48 Suppl 3:S44-S47. [PMID: 29025609 DOI: 10.1016/s0020-1383(17)30657-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Anaemia in patients with trochanteric fracture is associated with increased morbidity and mortality and it is an independent risk factor for functional mobility of patients. Several authors have reported the blood loss following operative treatment comparing different fixation systems but few authors have evaluated many associated variables that could influence the perioperative blood loss. PURPOSE To evaluate the blood loss in patients that had their trochanteric fracture stabilized with dynamic hip screw (DHS) or Gamma nail. Multivariate analysis of different variables that can influence blood loss was carried out (type of fracture, antiaggregant or anticoagulant therapy, time to surgery). The hypothesis was that there is no difference in terms of blood loss in patients with trochanteric fracture treated with DHS or Gamma nail considering all these variables. MATERIALS & METHODS Perioperative blood loss was evaluated in 417 consecutive patients treated for trochanteric fracture with DHS or Gamma nail between January 2010 and March 2013. The perioperative blood loss was calculated using the Lisander formula modified by Foss-Kehlet based on pre- and post-operative haemoglobin values and transfusion rates. Univariate and multivariate analysis were performed integrating the following variables: type of fracture (A1 vs A2), antiaggregant/anticoagulant therapy vs no therapy, time to surgery (<24 vs >24 hours from trauma), type of implant (DHS vs Gamma nail). RESULTS A significant blood loss (p <0.05) was observed between A1 and A2 fracture types (1247ml vs 1796.7ml), antiaggregant/anticoagulant therapy and no therapy (1592.7ml vs 1470.2ml), time-to-surgery <24 and >24 hours from trauma (1584.4ml vs 1323.9ml), DHS and Gamma nail (894.7ml vs 1720.6ml). At multivariate analysis, in the A1 fracture groups the DHS showed a significant lower blood loss compared to Gamma nail (p < 0.05). CONCLUSIONS According to the perioperative blood loss, DHS should be used in A1 fractures while Gamma nail can be taking in account for the unstable A2 fractures.
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Affiliation(s)
- Mario Ronga
- Department of Medicine and Health Sciences 'Vincenzo Tiberio', University of Molise, Campobasso - Italy; Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy.
| | - Daniele Bonzini
- Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Marco Valoroso
- Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Giuseppe La Barbera
- Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Jacopo Tamini
- Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Mario Cherubino
- Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
| | - Paolo Cherubino
- Orthopaedics and Traumatology, Department of Biotechnology and Life Sciences (DBSV), University of Insubria, Varese, Italy
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Augmentation of intramedullary nailing in unstable intertrochanteric fractures using cerclage wire and lag screws: a comparative study. Injury 2017; 48 Suppl 2:S18-S22. [PMID: 28802415 DOI: 10.1016/s0020-1383(17)30489-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Unstable intertrochanteric fractures present a challenge to orthopaedic surgeons, with varied geometry of the fractures and a wide choice of implants and techniques. The patients are usually osteoporotic, with multiple co-morbidities and poor tolerance for complications and re-operations. Lateral wall reconstruction and stability of the trochanteric fragments are considered important in providing a better outcome of these difficult injuries. We present a technique of lateral wall and trochanteric reconstruction using Cerclage wires and lag screws in the greater trochanter in addition to intramedullary nailing, and the radiological and functional outcome of this technique of augmentation. MATERIALS AND METHODS This prospective study includes 154 patients from 2010 to 2015 presenting to the institute with an unstable intertrochanteric fracture. They were sequentially operated with intramedullary nailing (IMN) and augmentation with cerclage wire and/or Anteroposterior screw in greater trochanter, and 77 patients with IMN only. Operating time and need for blood transfusion post-surgery were documented. Patients were followed up for minimum of 12 months and radiological union time, complications and functional outcome using Harris Hip Score were noted at 1 year. Statistical analysis was performed to compare the results in both groups RESULTS: The mean union was 3.6 months in group A and 4.1 months in group B, with no statistically significant difference. The operating time needed for augmentation was 10 minutes more than IMN only. Blood transfusion was not required in any case. The incidence of complications like screw cut out, back out and non-union was lower in augmented group, and good functional outcome was greater in the augmented group which was statistically significant. The reoperation rate was lower in augmented group. CONCLUSIONS This new technique of augmentation of fixation of intramedullary nail in unstable trochanteric fractures using cerclage wires and lag screws for lateral wall reconstruction is useful in reducing complications of the procedure and provides good radiological and functional outcome. It requires little additional operating time with minimal blood loss and soft tissue injury.
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