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

The Patient with Hip Fracture

Hip fractures are a frequent cause of hospitalization in the elderly population and can lead to significant morbidity and mortality. As the population continues to age, the incidence of hip fractures is expected to increase. The internist/hospitalist plays a critical role in the care of this population as many patients have multiple medical comorbidities. Management of the fragility hip fracture patient requires knowledge of several perioperative topics including preoperative risk assessment, risk reduction strategies, the optimal timing of surgical repair, venous thromboembolism prevention, and postoperative care considerations such as early mobilization with physical therapy, and osteoporosis treatment.

CT in musculoskeletal imaging: still helpful and for what?

Computed tomography (CT) is a common modality employed for musculoskeletal imaging. Conventional CT techniques are useful for the assessment of trauma in detection, characterization and surgical planning of complex fractures. CT arthrography can depict internal derangement lesions and impact medical decision making of orthopedic providers. In oncology, CT can have a role in the characterization of bone tumors and may elucidate soft tissue mineralization patterns. Several advances in CT technology have led to a variety of acquisition techniques with distinct clinical applications. These include four-dimensional CT, which allows examination of joints during motion; cone-beam CT, which allows examination during physiological weight-bearing conditions; dual-energy CT, which allows material decomposition useful in musculoskeletal deposition disorders (e.g., gout) and bone marrow edema detection; and photon-counting CT, which provides increased spatial resolution, decreased radiation, and material decomposition compared to standard multi-detector CT systems due to its ability to directly translate X-ray photon energies into electrical signals. Advanced acquisition techniques provide higher spatial resolution scans capable of enhanced bony microarchitecture and bone mineral density assessment. Together, these CT acquisition techniques will continue to play a substantial role in the practices of orthopedics, rheumatology, metabolic bone, oncology, and interventional radiology.

Classification of AO/OTA 31A/B femur fractures in X-ray images using YOLOv8 and advanced data augmentation techniques

Femur fractures are a significant worldwide public health concern that affects patients as well as their families because of their high frequency, morbidity, and mortality. When employing computer-aided diagnostic (CAD) technologies, promising results have been shown in the efficiency and accuracy of fracture classification, particularly with the growing use of Deep Learning (DL) approaches. Nevertheless, the complexity is further increased by the need to collect enough input data to train these algorithms and the challenge of interpreting the findings. By improving on the results of the most recent deep learning-based Arbeitsgemeinschaft für Osteosynthesefragen and Orthopaedic Trauma Association (AO/OTA) system classification of femur fractures, this study intends to support physicians in making correct and timely decisions regarding patient care. A state-of-the-art architecture, YOLOv8, was used and refined while paying close attention to the interpretability of the model. Furthermore, data augmentation techniques were involved during preprocessing, increasing the dataset samples through image processing alterations. The fine-tuned YOLOv8 model achieved remarkable results, with 0.9 accuracy, 0.85 precision, 0.85 recall, and 0.85 F1-score, computed by averaging the values among all the individual classes for each metric. This study shows the proposed architecture's effectiveness in enhancing the AO/OTA system's classification of femur fractures, assisting physicians in making prompt and accurate diagnoses.

Diagnostic Value of Ultrasound for Sternal Fractures in Patients with Trauma Experiencing Anterior Chest Wall Pain

Background: Ultrasound is an attractive modality for the confirmation of sternal fractures in patients with trauma because of its easy, quick, and accurate nature, as well as its increased availability for focused assessment with sonography for trauma at the bedside. We aimed to confirm the diagnostic value of ultrasonography for sternal fractures in patients with trauma, anterior chest wall pain, and tenderness. Methods: This retrospective observational study included patients visiting a single regional trauma center from March 2022 to February 2023, diagnosed with sternal fractures via chest CT and bone scans, who underwent sternal ultrasound. Results: Twenty-six patients were divided into two groups: those with sternal fractures diagnosed with an initial chest CT scan (n = 19) and those without fractures (n = 7). Using ultrasound, 23 patients (88.5%) were diagnosed with sternal fractures. In the initial CT scan (+) group, all 19 patients (100%) were diagnosed using ultrasound. In the initial CT scan (-) group, four (57.1%) of the seven patients were diagnosed using ultrasound. In the initial CT scan (+) group, 14 (73.7%) of the 19 patients underwent bone scans and all 14/14 (100%) were diagnosed with sternal fractures. In the initial CT scan (-) group, seven (100%) patients underwent bone scans, and all were diagnosed with sternal fractures. Conclusions: Ultrasound is useful for the diagnosis of sternal fractures, with sensitivity of 88.5%. Therefore, in patients with blunt trauma experiencing anterior chest wall pain and tenderness, sternal ultrasonography might be helpful in diagnosing sternal fractures as an adjunct to chest CT and bone scans.

Occult Intertrochanteric Fracture Detected by Bone Scan Imaging: A Case Report

Femoral intertrochanteric fractures can be occult and not visible on plain radiographs, even when there is a high clinical suspicion. This case study reports an occult intertrochanteric fracture that was diagnosed using a bone scan rather than an MRI or CT scan. A 91-year-old woman arrived at the emergency room with a complaint of left hip pain after slipping at home. Clinical examination revealed tenderness, mild swelling, limited range of motion, and an inability to bear weight. Radiographs and CT scans of the hip and pelvis showed no evidence of a fracture. An MRI was planned, but the patient's agitation resulted in improper images. Consequently, a bone scan identified an ill-defined focal area with slightly increased activity, consistent with an intertrochanteric femur fracture. In such challenging scenarios, bone scans can still serve as an alternative diagnostic tool, aiding in clinical decision-making.

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

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

MRI in suspected chest wall fractures: diagnostic value in work-related chest blunt trauma

OBJECTIVE

To describe and analyze MRI findings in suspected early fractures of the chest (ribs and sternum) and assess if this technique can add value in occupational medicine.

MATERIALS AND METHODS

In this retrospective study, we reviewed 112 consecutive patients with work-related mild closed chest trauma who underwent early thoracic MRI, when there was not a clear fracture on radiograph or when the symptoms were intense and not explained by radiographic findings. MRI was evaluated by two experienced radiologists independently. The number and location of fractures and extraosseous findings were recorded. A multivariate analysis was performed to correlate the fracture characteristics and time to RTW (return-to-work). Interobserver agreement and image quality were assessed.

RESULTS

100 patients (82 men, mean age 46 years, range 22-64 years) were included. MRI revealed thoracic wall injuries in 88%: rib and/or sternal fractures in 86% and muscle contusion in the remaining patients. Most patients had multiple ribs fractured, mostly at the chondrocostal junction (n=38). The interobserver agreement was excellent, with minor discrepancies in the total number of ribs fractured. The mean time to return-to-work was 41 days, with statistically significant correlation with the number of fractures. Time to return-to-work increased in displaced fractures, sternal fractures, extraosseous complications, and with age.

CONCLUSION

Early MRI after work-related chest trauma identifies the source of pain in most patients, mainly radiographically occult rib fractures. In some cases, MRI may also provide prognostic information about return-to-work.

Reporting of Full-Length Femur Imaging to Detect Incomplete Atypical Femur Fractures: 2023 Official Positions of the International Society for Clinical Densitometry

Incomplete atypical femur fractures (iAFFs) are associated with the long-term use of anti-resorptive therapies. Although X-rays are typically used to screen for iAFFs, images from dual-energy X-ray absorptiometry (DXA) offer an alternate method for detecting iAFFs. Although a previous 2019 ISCD Official Position on this subject exists, our task force aimed to update the literature review and to propose recommendations on reporting findings related to iAFFs that may be observed on DXA images. The task force recommended that full-length femur imaging (FFI) from DXA can be used as a screening tool for iAFFs. The presence of focal lateral cortical thickening and transverse lucencies should be reported, if identified on the FFI. This task force proposed a classification system to determine the likelihood of an iAFF, based on radiographic features seen on the FFI. Lastly, the task force recommended that the clinical assessment of prodromal symptoms (pain) is not required for the assessment of FFI.

Improving traumatic fracture detection on radiographs with artificial intelligence support: a multi-reader study

Objectives

The aim of this study was to evaluate the diagnostic performance of nonspecialist readers with and without the use of an artificial intelligence (AI) support tool to detect traumatic fractures on radiographs of the appendicular skeleton.

Methods

The design was a retrospective, fully crossed multi-reader, multi-case study on a balanced dataset of patients (≥2 years of age) with an AI tool as a diagnostic intervention. Fifteen readers assessed 340 radiographic exams, with and without the AI tool in 2 different sessions and the time spent was automatically recorded. Reference standard was established by 3 consultant radiologists. Sensitivity, specificity, and false positives per patient were calculated.

Results

Patient-wise sensitivity increased from 72% to 80% (P < .05) and patient-wise specificity increased from 81% to 85% (P < .05) in exams aided by the AI tool compared to the unaided exams. The increase in sensitivity resulted in a relative reduction of missed fractures of 29%. The average rate of false positives per patient decreased from 0.16 to 0.14, corresponding to a relative reduction of 21%. There was no significant difference in average reading time spent per exam. The largest gain in fracture detection performance, with AI support, across all readers, was on nonobvious fractures with a significant increase in sensitivity of 11 percentage points (pp) (60%-71%).

Conclusions

The diagnostic performance for detection of traumatic fractures on radiographs of the appendicular skeleton improved among nonspecialist readers tested AI fracture detection support tool showed an overall reader improvement in sensitivity and specificity when supported by an AI tool. Improvement was seen in both sensitivity and specificity without negatively affecting the interpretation time.

Advances in knowledge

The division and analysis of obvious and nonobvious fractures are novel in AI reader comparison studies like this.

Value of Proximal Femur Geometry in Predicting Occult Hip Fracture

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.

Radiologic blind spots in hip and pelvic radiographs

PURPOSE

The purpose of our study was to identify the locations at which hip and pelvic fractures are commonly missed on radiographs.

METHODS

A retrospective study was performed at four non-Level 1 trauma center emergency departments. IRB approval was obtained. All emergency department hip or pelvic radiographs with subsequent CT performed within 48 h were identified from 2017 to 2022. Reports for each radiograph and CT were scored for the presence or the absence of fracture in the following locations: ilium, sacrum, superior pubic ramus, inferior pubic ramus, pubis, acetabulum, subcapital femoral, femoral neck, greater trochanter, lesser trochanter, intertrochanteric, and subtrochanteric. The CT report was used as the gold standard. The false-negative radiography cases were reviewed on a PACS workstation to determine whether the case had an "unexpected miss" of a fracture, a subtle fracture, radiographically occult fracture, or exam was limited by artifact. The percentage of missed fractures at each location was calculated.

RESULTS

Nine hundred seventy-five radiography cases with subsequent CT were identified. One hundred forty-six cases did not meet entry criteria; therefore, 829 cases were analyzed further. Seventy-four percent of patients were female with age of 74 ± 16 (mean ± standard deviation) years (range 1-103). Three hundred fifty-two cases had at least one fracture, and many cases had multiple fractures. There were 68 false-negative cases. The most commonly missed fractures by percentage were pubis, ilium, and greater trochanter. The most common unexpectedly missed fractures were greater trochanter and femoral subcapital.

CONCLUSION

A careful systematic evaluation of hip and pelvic radiographs, with particular attention to the pubis, ilium, greater trochanter, and subcapital region, may improve radiographic fracture detection and decrease delays in diagnosis.

A Scientific Proposal for Surgical Decision-Making in Occult Intertrochanteric Fractures Based on Finite Element Analysis

Background In the treatment of femoral intertrochanteric fractures, there is still a lack of consensus on the optimal approach for isolated greater trochanteric fractures and insufficient intertrochanteric fractures. The limited number of patients and restricted access to accurate assessment of fracture extension using magnetic resonance imaging contribute to the unclear treatment strategy. This study aims to utilize finite element (FE) analysis to analyze stress values at the fracture line and investigate their influence on intertrochanteric fracture extension under different loading conditions. The hypothesis is that fracture extension occurs following certain conditions, supporting the need for surgery based on scientific evidence. Methodology Osseous data from a computed tomography (CT) scan was used to create a proximal femur FE model using FEA software. CT scan data were converted to Digital Imaging and Communications in Medicine format and used to generate the FE model. Trabecular bone and cortex were meshed into tetrahedral elements. The model consisted of 1,592,642 elements and 282,530 nodes. Two models were created, namely, healthy proximal femur (HF) and femoral insufficient intertrochanteric fracture (FIF). Material properties were assigned based on CT values and conversion equations. The distal end of the femur was constrained. Stress analysis using the dynamic explicit approach was performed. Von Mises stresses were calculated for the proximal femur. The number of elements exceeding yield stress was counted to predict fracture risk by focusing on fracture line spots. In this study, the distribution of von Mises stress was compared between the HF and the FIF models. Six loading combinations were considered, namely, two weight-bearing conditions (3 W loading simulating for walking and 1/3 W for touch-down standing) and three hip flexion angles (0°, 15°, and 23°). Results Under 3 W loading, no significant stress elevations were observed in the HF model at any flexion angles. However, the FIF model exhibited increased stress at the site of the posterior fracture line extension. This stress-induced element destruction was observed in both cortical and cancellous bone. For the 1/3 W loading condition, only minimal stress elevation was observed in both HF and FIF models. To assess the influence on fracture extension, the number of yielded elements was evaluated along the fracture line edges (greater trochanter and middle of the intertrochanteric ridge). Under 3 W loading, the HF model had only one yielded element, indicating minimal fracture risk. In contrast, the FIF model exhibited a notable presence of yield elements in various regions (total/greater trochanter/shaft) at different flexion angles: 0° (115/16/28), 15° (265/158/23), and 23° (446/233/34). Under the 1/3 W loading condition, neither the HF nor the FIF models showed any yielding elements, regardless of the direction of external force. Conclusions The results demonstrated elevated stress levels at the fracture line in the FIF model, particularly during walking, indicating a higher risk of fracture extension at the flex position. However, under reduced weight-bearing conditions, the stress at the fracture site remained within the yield stress range, suggesting a relatively low risk of fracture extension. These findings hold significant clinical implications for developing surgical protocols that consider patients' compliance with weight-bearing restrictions.

Hip effusions or iliopsoas hematomas on ultrasound in identifying hip fractures in the emergency department

OBJECTIVE

We evaluated the sensitivity, specificity, predictive values, and likelihood ratios of hip effusion and/or iliopsoas hematoma on point-of-care ultrasound (POCUS) performed by ultrasound fellows and fellowship trained emergency providers to identify hip fractures in emergency department (ED) patients with a high suspicion of hip fracture.

METHODS

This was a prospective observational study of a convenience sample of patients with high suspicion of hip fracture at two academic EDs between 2018 and 2021. Patients with negative x-rays who did not receive further imaging with magnetic resonance imaging (MRI) or computed tomography (CT) were excluded. Sonographers were blinded to clinical data and ED imaging results. At the primary site, 8 ultrasound fellows and 4 emergency ultrasound fellowship-trained emergency providers performed the ultrasonographic examinations. At the secondary site, 2 ultrasound fellows, 4 emergency ultrasound-fellowship trained physicians, and 1 sports medicine fellowship-trained emergency provider performed the ultrasonographic examinations. A positive ultrasound was defined as either the presence of a hip effusion or iliopsoas hematoma on the affected extremity. The primary outcome measures were sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) of POCUS findings for identification of a hip fracture compared with a ranked composite reference standard consisting of x-ray, CT, or magnetic resonance imaging (MRI); the highest-level test performed for each patient was used for comparison.

RESULTS

Among 213 patients analyzed, all 213 received an x-ray, 116 received a CT scan, and 14 received an MRI; 113/213 x-rays (53.1%), 35/116 CT scans (30.2%), and 7/14 MRIs (50.0%) were positive for a hip fracture. A total of 123 patients were diagnosed with a hip fracture (57.7%). There were 13 false negative x-ray results. Overall, compared with the reference standard of x-ray, CT, or MRI, POCUS had a sensitivity of 97% (95% CI: 94%, 100%), specificity of 70% (95% CI: 61%, 79%), PPV of 82% (95% CI: 75%, 88%), and NPV of 94% (95% CI: 88%, 100%) in the identification of hip fractures; with a positive likelihood ratio of 3.22 (95% CI: 2.35, 4.43) and negative likelihood ratio of 0.05 (95% CI: 0.02, 0.12).

CONCLUSION

In a convenience sample of ED patients with high clinical suspicion for hip fracture, the presence of a hip effusion and/or iliopsoas hematoma on POCUS performed by expert emergency ultrasonographers showed high sensitivity in diagnosing patients with a hip fracture.

Musculoskeletal Trauma and Infection

MR is often the most definitive imaging for assessment of musculoskeletal trauma and infection. Although it is not possible to address all the intricacies of these complex topics in a single article, this review will attempt to provide a useful toolbox of skills by discussing several common clinical scenarios faced by emergency radiologists in interpretation of adult trauma and infection. These scenarios include MR assessment of hip and pelvic fracture, traumatic soft tissue injuries, septic arthritis, soft tissue infection, and osteomyelitis.

Evidence-based intervention on postoperative fear, compliance, and self-efficacy in elderly patients with hip fracture

BACKGROUND

Elderly patients tend to have poor self-efficacy and poor confidence in postoperative rehabilitation for hip fractures, and are prone to negative emotions, which affect treatment compliance.

AIM

To evaluate the effects of evidence-based intervention on postoperative fear, compliance, and self-efficacy in elderly patients with hip fractures.

METHODS

A total of 120 patients with hip fracture surgically treated from June 2018 to June 2020 at the orthopedic department of our hospital were selected and divided into intervention and routine groups (n = 60 each) according to different nursing methods. The basic rehabilitation methods of the two groups were consistent, but patients in the intervention group received evidence-based nursing interventions at the same time. Differences between groups in the scores of motion phobia, pain fear, rehabilitation training compliance, self-efficacy, nursing satisfaction, and hip joint function were compared before and after the intervention.

RESULTS

Before the intervention, there were no statistically significant differences in motion phobia and pain fear scores between the groups (all P > 0.05). However, motion phobia scores at 1 wk after intervention initiation (P < 0.05), and pain fear scores at 1 wk and 2 wk after intervention initiation (all P < 0.05), were significantly lower in the intervention group than in the routine group. On the first day of intervention, there was no significant difference in rehabilitation treatment compliance between the groups (P > 0.05); however, at 2 wk after intervention initiation, rehabilitation compliance was significantly better in the intervention group than in the routine group (P < 0.05). Before the intervention, there were no statistically significant differences in the scores for the two self-efficacy dimensions (overcoming difficulties and rehabilitation exercise self-efficacy) and the total self-efficacy score between the groups (all P > 0.05). After 2 wk of intervention, the scores for these two dimensions of self-efficacy and the total self-efficacy score were significantly higher in the intervention group than in the routine group (all P < 0.05). At 3 and 6 mo after surgery, hip function as evaluated by the Harris hip score, was significantly better in the intervention group than in the routine group (P < 0.05). Additionally, overall nursing satisfaction was significantly higher in the intervention group than in the routine group (P < 0.05).

CONCLUSION

Evidence-based nursing intervention can alleviate fear of postoperative rehabilitation in elderly patients who underwent hip fracture surgery, and improve rehabilitation treatment compliance and patient self-efficacy, which promote hip function recovery.

The Necessity of CT Hip Scans in the Investigation of Occult Hip Fractures and Their Effect on Patient Management

The diagnostic challenge of negative plain radiography in the context of a previously ambulatory patient is increasing with the rise in geriatric trauma. These patients are often diagnosed with small undisplaced fractures of the pelvis and femur which may not alter management. This study aims to assess the frequency at which computed tomography (CT) hip scans altered patient management and whether two X-ray projections of the hip affected fracture detection rate. All CT hip scans performed over a three-year period were identified retrospectively. Only CT hips pertaining to the identification of occult fractures were included in the study. A total of 447 (63.6%) CT hips were performed to exclude an occult fracture, which was only detected in 108 (24.1%) of the scans requested. The majority were subcapital (n = 58, 53.7%) or intertrochanteric (n = 39, 36.1%). There was no significant difference between fracture detection rates when comparing one and two views of the pelvis. 82.4% (n = 89) of occult hip fractures were managed operatively. CT imaging led to a change in patient management in 20% of cases. The frequency at which CT scan detects and alters management in occult hip fractures confirms the justification for its use. Increasing the number of X-ray projection views does not decrease the reliance on CT. Pelvic ring fractures are common in nonambulatory patients following trauma, and if confirmed on initial imaging, subsequent imaging to exclude a concurrent occult hip is unnecessary. The focus of further research should be towards the development of investigation algorithms which decrease the reliance on CT and defining the optimal surgical criteria for occult hip fractures.

Current concepts in the management of bisphosphonate associated atypical femoral fractures

Bisphosphonates are a class of drugs used as the mainstay of treatment for osteoporosis. Bisphosphonates function by binding to hydroxyapatite, and subsequently targeting osteoclasts by altering their ability to resorb and remodel bone. Whilst aiming to reduce the risk of fragility fractures, bisphosphonates have been associated with atypical insufficiency fractures, specifically in the femur. Atypical femoral fractures occur distal to the lesser trochanter, until the supracondylar flare. There are a number of the differing clinical and radiological features between atypical femoral fractures and osteoporotic femoral fractures, indicating that there is a distinct difference in the respective underlying pathophysiology. At the point of presentation of an atypical femoral fracture, bisphosphonate should be discontinued. This is due to the proposed inhibition of osteoclasts and apoptosis, resulting in impaired callus healing. Conservative management consists primarily of cessation of bisphosphonate therapy and partial weightbearing activity. Nutritional deficiencies should be investigated and appropriately corrected, most notably dietary calcium and vitamin D. Currently there is no established treatment guidelines for either complete or incomplete fractures. There is agreement in the literature that nonoperative management of bisphosphonate-associated femoral fractures conveys poor outcomes. Currently, the favoured methods of surgical fixation are cephalomedullary nailing and plate fixation. Newer techniques advocate the use of both modalities as it gives the plate advantage of best reducing the fracture and compressing the lateral cortex, with the support of the intramedullary nail to stabilise an atypical fracture with increased ability to load-share, and a reduced bending moment across the fracture site. The evidence suggests that cephalomedullary nailing of the fracture has lower revision rates. However, it is important to appreciate that the anatomical location and patient factors may not always allow for this. Although causation between bisphosphonates and atypical fractures is yet to be demonstrated, there is a growing evidence base to suggest a higher incidence to atypical femoral fractures in patients who take bisphosphonates. As we encounter a growing co-morbid elderly population, the prevalence of this fracture-type will likely increase. Therefore, it is imperative clinicians continue to be attentive of atypical femoral fractures and treat them effectively.

Clinical utility of a focused hip MRI for assessing suspected hip fracture in the emergency department

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.