Emergency department evaluation and treatment of hip and thigh injuries

Student radiographers' knowledge and experience of lateral hip X-ray positioning: A survey

INTRODUCTION

The horizontal beam lateral (HBL) position technique for X-ray imaging has been used for nearly a century; however, this can be challenging for the patient and the practitioner, as it potentially compromises patient dignity. This study explores student radiographers' knowledge and experience of lateral hip positions and their impact on diagnostic quality and patient dignity.

METHOD

A cross-sectional mixed-method online survey of undergraduate diagnostic radiography students was completed. Likert scale assessments, rank ordering questions, and free-test qualitative responses were utilised for questions on knowledge and experience of different positioning, ease to obtain, patient dignity, diagnostic quality, and need for repeats. Data analysis included descriptive statistics and cross-tabulation non-parametric analysis against variables of age, gender and year of study.

RESULTS

Responses were received by n = 42/158 students, a response rate of 27%. The HBL position was the most commonly repeated image (76.6%); the qualitative themes included HBL image quality issues and difficulty in the HBL positioning for elderly or frail patients, often in discomfort and pain. Analysis of student responses to perceived patient dignity in positioning identified 73.8% found the HBL undignified, and 85.7% agreed the Clements-Nakayama (CN) position would be more dignified for patients. The diagnostic image quality of the HBL position (64.2%) was compared to the CN alternative axiolateral (66.6%). Comparison of ease of obtaining the correct position for HBL (47.6%) was higher than CN position (28.6%); this could be due to the lack of experience n = 3/42 (7.1%) of this position.

CONCLUSION

Overall, student radiographers' experience and knowledge of various lateral hip positions observed in clinical practice was good. The CN position scored high for diagnostic image (66.6%) and dignity for the patient (85.7%), over the often repeated HBL position (76.6%), which scored lower for image quality (64.2%) and dignity (76.6%).

IMPLICATIONS FOR PRACTICE

Radiographers should advocate for professional autonomy and explore alternative positioning techniques. Further investigation into the CN position's utilisation, image quality and radiation dose in England is recommended.

External Validation of Deep Learning Algorithm for Detecting and Visualizing Femoral Neck Fracture Including Displaced and Non-displaced Fracture on Plain X-ray

This study aimed to develop a method for detection of femoral neck fracture (FNF) including displaced and non-displaced fractures using convolutional neural network (CNN) with plain X-ray and to validate its use across hospitals through internal and external validation sets. This is a retrospective study using hip and pelvic anteroposterior films for training and detecting femoral neck fracture through residual neural network (ResNet) 18 with convolutional block attention module (CBAM) +  + . The study was performed at two tertiary hospitals between February and May 2020 and used data from January 2005 to December 2018. Our primary outcome was favorable performance for diagnosis of femoral neck fracture from negative studies in our dataset. We described the outcomes as area under the receiver operating characteristic curve (AUC), accuracy, Youden index, sensitivity, and specificity. A total of 4,189 images that contained 1,109 positive images (332 non-displaced and 777 displaced) and 3,080 negative images were collected from two hospitals. The test values after training with one hospital dataset were 0.999 AUC, 0.986 accuracy, 0.960 Youden index, and 0.966 sensitivity, and 0.993 specificity. Values of external validation with the other hospital dataset were 0.977, 0.971, 0.920, 0.939, and 0.982, respectively. Values of merged hospital datasets were 0.987, 0.983, 0.960, 0.973, and 0.987, respectively. A CNN algorithm for FNF detection in both displaced and non-displaced fractures using plain X-rays could be used in other hospitals to screen for FNF after training with images from the hospital of interest.

Diagnostic strategy for elderly patients with isolated greater trochanter fractures on plain radiographs

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.

Accuracy of a modified axiolateral radiographic hip projection in suspected cases of hip fracture: experience and results from a regional trauma centre

Conventional radiographs play an important role as a first line imaging modality in the assessment for suspected hip fractures in the majority of trauma centres. The routinely performed radiographic projections in our emergency department for patients with clinically suspected hip fractures include antero-posterior (AP) and cross-table lateral views of the affected hip. Certain clinical scenarios which include the presence of significant pain of the injured lower limb, a large patient habitus, as well as pre-existing patient morbidity which would limit the range of motion of the lower limbs, for example the presence of prior joint replacement surgery or lower limb contractures, may however preclude proper positioning of the patient to obtain an optimal cross-table lateral view of the affected hip. The objective of this study is to investigate whether a modified axiolateral hip projection would be a feasible alternative to the cross-table lateral projection in the initial radiographic assessment of suspected cases of hip fracture.

Emergency Magnetic Resonance Imaging of Musculoskeletal Trauma

Musculoskeletal (MSK) trauma is commonly encountered in the emergency department. Computed tomography and radiography are the main forms of imaging assessment, but the use of magnetic resonance (MR) imaging has become more common in the emergency room (ER) setting for evaluation of low-velocity/sports-related injury and high-velocity injury. The superior soft tissue contrast and detail provided by MR imaging gives clinicians a powerful tool in the management of acute MSK injury in the ER. This article provides an overview of techniques and considerations when using MR imaging in the evaluation of some of the common injuries seen in the ER setting.

An interventional study to improve the quality of analgesia in the emergency department

Objective:

We sought to document the adequacy of acute pain management in a high-volume urban emergency department and the impact of a structured intervention.

Methods:

We conducted a prospective, single-blind, pre- and postintervention study on patients who suffered minor-to-moderate trauma. The intervention consisted of structured training sessions on emergency department (ED) analgesia practice and the implementation of a voluntary analgesic protocol.

Results:

Preintervention data showed that only 340 of 1000 patients (34%) received analgesia. Postintervention data showed that 693 of 700 patients (99%) received analgesia, an absolute increase of 65% (95% CI 61%–68%), and that delay to analgesia administration fell from 69 (standard deviation [SD] 54) minutes to 35 (SD 43) minutes. Analgesics led to similar reductions in visual analog pain scale ratings during the pre- and postintervention phases (4.5 cm, SD 2.0 cm, and 4.3 cm, SD 3.0 cm, respectively).

Conclusion:

Our multifaceted ED pain management intervention was highly effective in improving quality of analgesia, timeliness of care and patient satisfaction. This protocol or similar ones have the potential to substantially improve pain management in diverse ED settings.

Lumbar plexus block via a femoral approach for total hip arthroplasty dislocation reduction: a report of 2 cases

The incidence of hip dislocation can vary based on factors including age and patient co-morbidities. Prosthetic hip dislocations present a particularly difficult challenge. Although many cases are treated in the emergency setting using procedural sedation for reduction, some may require general anesthesia. We report two cases in which lumbar plexus blockade was used as the primary means for successful hip prosthesis dislocation reduction.

Imaging choices in occult hip fracture

BACKGROUND

Hip fracture is a common injury, with an incidence rate of > 250,000 per year in the United States. Diagnosis is particularly important due to the high dependence on the integrity of the hip in the daily life of most people.

OBJECTIVES

In this article we review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality.

DISCUSSION

Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3-4% of Emergency Department (ED) patients having hip X-ray studies who harbor an occult hip fracture, the Emergency Physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include computed tomography, scintigraphy, and magnetic resonance imaging.

CONCLUSION

We present an evidence-based algorithm for the evaluation of a patient suspected to have an occult hip fracture in the ED. Also outlined are future directions for research to distinguish more effective techniques for identifying occult hip fractures.

US emergency department visits for hip fracture, 1992???2000

BACKGROUND

Hip fracture is a significant injury for older persons. Little has been reported about emergency department (ED) care of these patients.

OBJECTIVE

To characterize the management of older patients treated in the ED for hip fracture with specific attention to the use of analgesia.

METHODS

This study analysed data from the National Hospital Ambulatory Medical Care Survey ( approximately 400 hospitals report each year) for the years 1992-2000. We included records of patients who were at least 50 years old and had a diagnosis of hip fracture (International Classification of Disease, 9th revision, clinical modification 820-820.9) in any of the three fields allowed for recording diagnosis.

RESULTS

There were 1,935,000 ED visits ( approximately 215,000 a year), predominantly among older white women. The rate in those over 80 years old was 25 times that of the youngest group. Fifty-six per cent of patients received analgesia (44% narcotics). There were no ethnic or racial distinctions in the use of analgesia.

CONCLUSIONS

The ED visit presents a largely untapped opportunity for focused efforts in fall and hip fracture prevention, especially in countries with comprehensive geriatric services and well integrated healthcare delivery systems. Despite the high likelihood of pain, the administration of analgesics appears to be low and may be a worthy focus for practice improvement.

Prevalence and Patterns of Occult Hip Fractures and Mimics Revealed by MRI

OBJECTIVE

The diagnosis of hip fractures can be difficult on radiography alone. MRI is frequently used to confirm or deny the presence of a minimally displaced hip fracture. This study evaluates the patterns of injury seen on MRI that are difficult to diagnose on radiography.

MATERIALS AND METHODS

MRIs of 73 patients who were examined for possible hip fractures and whose radiographic findings were negative or equivocal for hip fracture were reviewed. Seventy-six studies were performed in 73 patients who were between 24 and 102 years old. MRIs were evaluated for the presence and location of bone or soft-tissue injury. Muscle injuries were categorized on the basis of location and type of injury.

RESULTS

Forty-six percent (35/76) of the studies showed subtle fractures. Seventeen fractures were in the proximal femur and 18 in the innominate bone. Soft-tissue abnormalities were common, found in 65% of the studies. Twenty percent of the MRI findings were considered normal because there was no apparent finding on the images to explain the patients' symptoms.

CONCLUSION

Soft-tissue abnormalities are commonly seen alone or in association with subtle fractures on MRI in the evaluation of patients with a clinical suspicion of hip fracture. MRI is recommended for all symptomatic patients whose radiographic findings are negative for hip fracture.

Factors influencing prehospital and emergency department analgesia administration to patients with femoral neck fractures

OBJECTIVES

To assess the analgesia practices of ambulance personnel and emergency department staff treating patients with fractured neck of femur.

METHODS

This is a retrospective analysis of 176 patients with an admission diagnosis of fractured neck of femur, who presented to a major western Sydney teaching hospital, between January and November 1999.

RESULTS

One hundred and twenty-eight patients met the inclusion criteria. The median age was 82, there were more female than male subjects. Ambulance officers made a clinical diagnosis of fractured neck of femur in 68% of cases. In 49% of cases no analgesia was given. Patients were given a higher triage category and pain relief faster if they had been given analgesia by ambulance officers, P = 0.0018 and P = 0.002, respectively. The median time to analgesia was 2 h 48 min.

CONCLUSIONS

Only a modest proportion of patients with fractured neck of femur received prehospital analgesia and delays to analgesia in the emergency department are considerable. Strategies to address the delivery of appropriate analgesia to this group of patients should be developed.