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The advantages of MRI in the detection of occult hip fractures
Abstract
While the displaced hip fracture can be visualized easily by plain radiography, the non-displaced fracture may be radiographically occult and require different imaging modalities, e.g., MRI for proper visualization. The accuracy of readers and cost advantages of utilizing MRI have not been assessed. Therefore, we undertook a study of these factors. The medical records of all patients who had visited the emergency room from June 2002 until May 2003 with a clinically suspected hip fracture, negative or equivocal plain film and subsequent MRI examination were retrospectively reviewed. Two senior and two junior radiologists independently evaluated both the MR images and radiographs of all 33 patients in a blinded study. One of three possible evaluations was described for the images of each modality: absence, presence or possibility of fracture. The economic consequences of using MRI in the detection of occult hip fractures were calculated. For all four doctors participating in this study, MRI proved to be far more sensitive and specific in the detection of occult hip fractures than radiography. Using the MR images, the senior radiologists identified the occult hip fracture patients with 100% accuracy and were in complete agreement. The agreement between junior and senior radiologists was high (average kappa=0.75). MRI also detected soft tissue injuries in 39% of the patients that could not be identified with radiography. Adoption of the new protocol using MRI saves hospitals from Euro 242 to 627 per patient. By shortening the time to diagnosis and permitting a superior visualization of both bone and soft tissue injuries, MR imaging prevents unnecessary hospitalization and delays in definitive treatment. MR images should be assessed by senior radiologists.
... The prevalence of OHF is reported to be between 2-10% (5,6). Previously, MRI has been reported to be 100% accurate in the diagnosis of an occult hip fracture (7). While CT may be quicker & easier to obtain, and in some studies demonstrated equal efficacy at identifying fractures (8) MRI offers the additional benefit of diagnosing alternative soft tissue pathology (9). ...
... The study also confirms the benefit of MRI in identifying fracture configurations especially with fractures of the greater trochanter (7). With fracture line propagation extending across the intertrochanteric region, surgical fixation can be undertaken confirming the findings from other studies (13). ...
... MRI is superior to plain radiographs, computer typography (CT) and bone scintigraphy for the early detection of an occult hip fracture (7,14). Additionally, as well as being 100% specific and selection bias as only patients who underwent MRI scans were included. ...
Elderly patients who present with an inability to weight bear following a fall, with normal radiographs, should be appropriately investigated to rule out an occult hip fracture (OHF). We aim to identify both the range and incidence of the differential diagnosis of acute traumatic hip pain in a large series of patients investigated for OHF. A retrospective analysis of consecutive patients investigated for an OHF with magnetic resonance imaging (MRI) was performed. Dedicated musculo-skeletal radiologists reported the MRI scans. All diagnoses including hip fractures, other fractures and soft tissue injuries were recorded. Case notes were reviewed for all patients to identify subsequent complications, management and outcomes. A total of 157 patients fulfilled the inclusion criteria. 52 (33%) patients had a fracture of the proximal femur. The majority of patients with proximal femoral fractures required surgical intervention. 9 patients who had fractures of the greater trochanter of the femur without fracture extension across the femoral neck were managed non-operatively. 40 (25%) patients had fractures of the pelvis, with a combined pubic rami and sacral fracture occurring frequently. The most common diagnosis was a soft tissue injury alone that was seen in 60 (38%) patients imaged. Injuries to the gluteal muscle group, iliopsaos complex and trochanteric bursa were most prevalent. All patients with soft tissue injuries or fractures of the pelvis were successfully managed non-operatively. This study highlights a wide range of differential diagnoses in elderly patients presenting with acute traumatic hip pain. The proximal femur was fractured in 33% of patients imaged for OHFs in our series. The most common diagnosis was a soft tissue injury around the hip and pelvis ; these injuries can be successfully managed without surgery.
... The estimated number of low-energy hip fracture in elderly patients is expected to rise from 1.7 million in the 90s to 6.3 million in 2050 worldwide [1]. Plain radiography is the cornerstone imaging modality, but radiographically occult fracture (ROF) of the hip and pelvis, defined as a fracture not visible on radiographs, is observed in 2 to 14% of the patients after low-energy trauma [2][3][4][5]. Diagnosis of ROF is necessary as undetected or delayed detection of ROF of the hip and pelvis are associated with higher morbidity and mortality [6][7][8]. Magnetic resonance imaging (MRI) is considered as the imaging modality of choice to assess suspected hip and pelvic fractures [2,[9][10][11][12][13][14]. ...
... Diagnosis of ROF is necessary as undetected or delayed detection of ROF of the hip and pelvis are associated with higher morbidity and mortality [6][7][8]. Magnetic resonance imaging (MRI) is considered as the imaging modality of choice to assess suspected hip and pelvic fractures [2,[9][10][11][12][13][14]. ...
... The most common MRI protocols to detect hip and pelvic fractures include T1-weighted spin-echo (SE) sequence in the coronal plane along with Short-Tau Inversion Recovery (STIR) or T2-weighted fast SE sequences with fat suppression in the coronal and transverse planes [6,11,13]. Several authors suggested an abbreviated protocol to decrease the examination time for elderly patients using fat-and fluid-sensitive sequences in the coronal imaging plane only [2,5,6,15]. ...
Purpose:
To compare the diagnostic performance of T2-weighted Dixon, T1-weighted and Short-Tau Inversion Recovery (STIR) MR images for the detection of radiographically occult fractures (ROF) of the hip and pelvis in elderly patients after low-energy trauma.
Materials and methods:
A total of 22 patients older than 50 years with suspected ROF after low-energy trauma was prospectively included. There were 9 men and 13 women, with a mean age of 80.9 years±12.5 (SD) (range: 52-100 years). T2-weighted Dixon, T1-weighted and STIR MR images were analyzed by 3 independent radiologists blinded to the clinical data and the results of other imaging examinations. Readers separately assessed each series of images for the presence of fractures on a per bone analysis. Diagnostic performance of each reader was compared for Dixon and non-Dixon sequences using contingency tables and McNemar test. Interobserver agreement was evaluated according to the Fleiss-Cuzick's kappa statistics.
Results:
The sensitivity of the Dixon sequence in the detection of ROF ranged from 90.9% (20/22; 95% CI: 70.8-98.9%) to 100% (22/22; 95% CI: 84.6-100%). The sensitivities of the non-Dixon sequences in the detection of ROF ranged from 95.5% (21/22; 95% CI: 77.2-99.9%) to 100% (22/22; 95% CI: 84.6-100%). For each reader, there were no statistical differences between combined Dixon and combined non-Dixon images for the detection of ROF (P=0.12, 0.99 and 0.99). Interobserver agreement with T2-weighted Dixon water-only images was significantly lower than that with the STIR sequence (0.70-0.79 vs. 0.87-0.93).
Conclusion:
T2-weighted Dixon may be a second-rate alternative to T1-weighted and STIR sequences for the detection of ROF of the hip and pelvis in elderly patients.
... The occult hip fracture is a rare entity and occurs in 2% to 9% of patients presenting with hip trauma [7][8][9][10][11]. These fractures are not initially visible on plain radiography and diagnosis requires advanced imaging such as magnetic resonance imaging (MRI) and computed tomography (CT) scans [12][13][14]. Two studies that have attempted to characterise this group of patients have not found any difference in demographic or clinical characteristics of these patients [9,15]. ...
... Occult hip fractures in the elderly are rare and challenging to diagnose [7][8][9][10][11][12][13]. In our series, 4.8% of all patients presented with occult hip fractures. ...
... The available literature has focused largely on identifying the ideal diagnostic modality for occult hip fractures [7][8][9]. Whilst both CT and MRI scans have been shown to have high sensitivity in detecting occult hip fractures, multiple studies have found MRI scans to be superior [13,[19][20][21]. Other advantages of utilising MRI include the avoidance of radiation and the ability to identify other possible bony or soft tissue pathologies that may be contributing to pain. ...
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.
... 4 Assuming that the rest of Asia has similar hip fracture incidence rates, the total number of hip fracture occurrences in Asia alone will reach 3.66 million. 4 The emphasis on early surgical intervention in the management of hip fractures has been advocated in recent years in light of the significantly increased mortality rates and risk of pressure sores associated with surgical delay beyond 24-48 h. 5 Occult fractures constitute 2-10% of fragility hip fractures [6][7][8][9][10] and are associated with considerable delays in their diagnosis as they cannot be visualized on plain radiographs, which require advanced cross-sectional imaging to diagnose and a high index of suspicion to pick up. ...
... Magnetic resonance imaging (MRI) has traditionally been the gold standard imaging modality as the crosssectional imaging of choice in the investigation of occult hip fractures [10][11][12][13][14][15][16][17][18] (Figure 1). Unfortunately, these may not be readily accessible and are contraindicated in some patients. ...
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.
... 4 Verbeeten et al. found MRI specificity and sensitivity was near 100% for hip and pelvic fractures. 5 MRI also offers the ability to identify other soft tissue problems that may be the source of pain, such as tumors, muscle tears, and hematoma. ...
... Although previous studies found MRI to be more sensitive, most of these studies included a small number of patients and utilized older CT scanners. [2][3][4][5][6] Advances in CT scanner technology may improve the ability of modern CT to detect more subtle fractures. For example, Mallee et al. found comparable sensitivity, specificity, and accuracy when comparing MRI with 64 slice multidetector CT (MDCT). ...
Background:
Elderly patients who fall account for more than two million emergency department visits each year. In 4-10 % of these patients, initial plain radiographs do not identify a hip or pelvis fracture later diagnosed with advanced imaging. No consensus exists about what type of imaging, CT or MRI, should be obtained in elderly patients with hip or pelvic pain after a low energy trauma. The purpose of this study was to determine whether CT or MRI is more likely to result in a definitive fracture diagnosis in elderly patients with hip or pelvic pain after low energy trauma.
Methods:
A retrospective chart review was conducted of all patients who presented to the ED at a single level one trauma center over a 4.5 year period. Inclusion criteria were age greater than fifty years old, presentation with hip and/ or pelvis pain due to a low energy trauma, and radiographic imaging including both plain radiographs and at least one pelvis MRI or CT.
Results:
Of the 218 patients who met inclusion criteria and had negative initial plain radiographs, CT or MRI later diagnosed a fracture in 69 patients (32%). Seventy eight patients underwent MRI (24 fractures, 32%), 132 underwent CT imaging (41 fractures, 31%), and eight had both CT and MRI (5 fractures, 63%). Patients who underwent CT spent less time in the ED on average (430 minutes) than those who underwent MRI, or MRI and CT (502 minutes and 620 minutes respectively). Patients who underwent CT were just as likely to be diagnosed with a fracture as those who underwent MRI (p= 0.002). We encountered no cases where CT imaging did not identify a fracture that was later identified on MRI. Fifty six patients (26%) had at least one contraindication to MRI.
Conclusions:
Our study suggests CT may be adequate to rule out hip and pelvic fractures in this patient population. CT may be preferable to MRI based on decreased time spent in the ED and the large percentage of elderly patients with contraindications to MRI.Level of Evidence: III.
... However, conventional CT is not the only option for advanced imaging. The diagnostic accuracy of magnetic resonance imaging (MRI) in identifying occult fractures in the proximal femur is well described [17,18]. In patients with osteoporotic vertebra fractures, 16% of the patients increased in fracture classification severity after MRI [19]. ...
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.
... In-depth research has been done on the function of MRI in AVN, and it has been demonstrated to be a crucial modality in the diagnosis of the disease's early phases, 9,10 where a radiograph is unambiguous . MRI is a useful tool for detecting hidden bone and cartilage injuries such as stress fractures, 11 hidden fractures, infections, and musculoskeletal neoplasms . ...
Objectives: Hip pain can be diagnostic challenge for the clinician. Our study aimed to access the Role of Magnetic Resonance Imaging (MRI) in diagnosing hip pathologies. This study was retrospective study done on 55 patients refe Methods and materials: rred to Department of Radiodiagnosis, PESIMSR, Kuppam, Andhra Pradesh, India. All 55 patients were subjected to MRI hip study using T1, T2, STIR and PD FS sequences. Data collected was tabulated and statistical analysis was done. Out of 55 patients, 47 patients showed abnormality and 8 Results: patients had no abnormality detected. MRI is the modality of choice for the dia Conclusion: gnosis of hip joint pain as it is safe, non-invasive and depicts accurate anatomical details. MRI is an excellent modality for the diagnosis of many hip conditions which shows non remarkable subtle ndings in radiographs and CT.
... As MRI allows identification of the muscles, bone marrow, cortex, fascia, vessels and nerves with high contrast between them. Although MRI has no ionizing radiation and thus no biological hazards have been identified [3]. ...
Background: Magnetic Resonance Imaging (MRI) proved to be highly accurate imaging modality allows clear differentiation of the normal anatomic features of the hip. In addition to that it allows clear differentiation of the individual component of the normal joint from one another. The purpose of this work was to diagnose sports-related injuries of hip and groin using MR imaging with different sequences. Methods: This prospective study was carried out on59 athletic subjects presented clinically with different hip or groin joint complaints, both sexes within adult age. All patients were subjected to clinical examination, imaging (conventional radiography of both hips were performed mostly in antero-posterior and lateral views to detect fractures, dislocations, bony lesions or soft tissue swelling), MRI examinations and image analysis. Results: There was significant difference between MRI type of injuries and different age groups of studied sportive patient. MRI show lesion in 59 cases in comparison to X-ray which has less sensitivity as 46 case has negative results show lesions in MRI. Conclusions: MRI of the hip has established to be the gold standard for the diagnosis of sports-related hip and groin injuries in the setting of negative radiographs, also it can determine early signs of stress fracture before it appear in X-ray. so, more details about different lesions can be obtained from MRI and This help in accurate diagnosis, rapid treatment of different athlete lesions and determine time plane of returning to the sport by follow up imaging.
... These fractures are referred to as occult hip fractures and represent 2-10% of all nFNF [2][3][4][5][6]. MRI is more accurate than both CT and radionuclide bone scans to detect occult fractures and also reduce time to diagnosis [2,7,8]. Reoperation rates after internal fixation (IF) of nFNFs detected on plain radiographs range from 8 to 19% in previous reports [9]. ...
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.
... 3,4 Although MRI is currently the gold standard for detecting occult hip fractures (sensitivity and specificity = 100%), given the limited accessibility of MRI in the ED, as well as the high sensitivity and specificity of CT scan for occult hip fractures, it is generally recommended to obtain CT scans for patients with suspected occult hip fractures as a first-line investigation. 3,5,6 Topics: Shenton's line, hip fracture, transcervical fracture, subcapital fracture, pelvis CT, hip X-ray, trauma, comminuted fracture, impacted fracture, femoral neck fracture, orthopedics. ...
... Magnetic resonance imaging (MRI) is considered the gold standard investigation (10)(11)(12)(13) and has higher sensitivity and specificity than computed tomography (CT) (7,14); however, MRI is more expensive, time-consuming, and not readily available, particularly after-hours. CT is more available and cost-effective, but it uses ionizing radiation, is not as sensitive as MRI, and can miss trabecular fractures and soft tissue injuries (9). ...
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.
... Reader experience has been previously shown to contribute to diagnostic accuracy of MRI for radiographically occult hip fractures with more senior readers showing 100% accuracy [27]. Although a slight improvement in sensitivity was identified with radiologist readers compared with radiology residents and orthopedic surgeons, the specificity and accuracy were not significantly different. ...
OBJECTIVE. The purpose of this article is to provide a review of the imaging of spine fixation hardware. CONCLUSION. As the prevalence of neck and back pain continues to increase, so does the number of surgical procedures used to treat such pain. Accordingly, new techniques and hardware designs are used, and the hardware will be seen on postoperative imaging. It is critical that radiologists understand the appropriate imaging modalities for the assessment of spine fixation hardware, recognize the normal imaging appearance of such hardware, and be able to detect hardware-related complications.
... Reader experience has been previously shown to contribute to diagnostic accuracy of MRI for radiographically occult hip fractures with more senior readers showing 100% accuracy [27]. Although a slight improvement in sensitivity was identified with radiologist readers compared with radiology residents and orthopedic surgeons, the specificity and accuracy were not significantly different. ...
OBJECTIVE. The purpose of this article is to provide a step-by-step guide for bone imaging-guided percutaneous core needle biopsy, including the armamentarium available and the most recent advances. CONCLUSION. Bone imaging-guided percutaneous core needle biopsies are well-established, minimally invasive, cost-effective interventions for histologic characterization of bone lesions with an excellent safety profile and diagnostic outcomes; they play a crucial role in management of patients. Radiologists involved in the care of patients with bone lesions must be familiar with the various steps involved in such procedures and their role in patient management.
... But these symptoms also occur due to degenerative hip changes in elderly patients. This can confuse and complicate the medical occult femoral neck fracture diagnosis [5,13]. According to Hossain and other trials, painful axial load was monitored in 73 per cent, painful rotation in 70 per cent, and painful leg raise in 50 per cent of patients who had occult fractures. ...
Occult femoral neck fractures are becoming an urgent problem for aging population. In general the term “occult fracture” is used to denote fractures which are occult on plain radiographs, but found to be present on other imaging modalities or intra-operatively. Estimated incidence of occult femoral neck fracture is 2 to 10 per cent according to the literature. There is a risk of secondary fracture displacement, and other related complications in case of late diagnosis of these fractures. Timely diagnosis of these fractures in elderly patients improves treatment outcomes, reduces invalidity risk. The higher mortality rate is associated with well diagnosed femoral neck fractures whose treatment was delayed for reasons other than missing X-ray evidence of a fracture.
... 7 MRI provides information regarding osteoarthritis, stress fractures, avascular necrosis affecting the articulating bones. 8 Thus, this study was done to evaluate painful hip joint with radiography and MRI. Our objectives were to establish the agreement between findings of radiograph and MRI in evaluation of painful hip joint and to estimate the role of MRI in early evaluation of painful hip joints and to give differential diagnoses. ...
... In one series, CT showed a sensitivity of only 86% in detecting occult hip fractures, and contributed to an average delay in definitive diagnosis of 37 h [12]. In contrast, Verbeeten found MRI to have a sensitivity of 100% of detecting occult hip fractures in their series of 33 cases [13]. Iwata et al. found the T1 coronal reformatted images to be the most sensitive sequence [14]. ...
IntroductionAlthough surgical fixation is routinely recommended for geriatric hip fractures, nonoperative treatment may be an option for certain stable fracture patterns. Occult hip fractures are nondisplaced fractures not evident on radiographs, but display intraosseous edema on MRI. Our aim is to report the rate of nonoperative treatment failure in patients with occult geriatric hip fractures.Methods
All nonoperatively treated femoral neck or intertrochanteric femur fractures (AO/OTA 31A and 31B) from 2003 to 2018 were identified. Patients older than 65 years with negative radiographs but a hip fracture evident on MRI were included. Patients who died prior to fracture displacement or union were excluded. Charts and imaging were reviewed for demographic data, fracture type, clinical course, displacement, and whether corrective surgery was performed.ResultsOf 15 final study patients, there were 6 femoral neck and 9 intertrochanteric fractures. Two fractures displaced, both requiring surgery (2/15; 13.3%). Both displacements occurred in the femoral neck group (2/6; 33%) compared to none in the intertrochanteric cohort (0/9; 0%). This trend did not reach statistical significance (p = 0.14).Conclusion
Thirty-three percent (2/6, 33%) of femoral neck fractures displaced and required surgery. The remainder of the cohort (13/15, 87%) healed without complication, including all of the intertrochanteric fractures (9/9, 100%). Although this difference did not reach statistical significance, the results may better inform treatment discussions for geriatric patients with occult hip fractures diagnosed by MRI.Level of evidenceLevel III.
... 1,2 MRI gives valuable information about occult bony injuries and cartilage injuries as stress fractures, occult fractures, bone marrow disorders, infections & musculoskeletal neoplasms. 3 Contrast study with intravenous and intra-articular gadolinium is used to diagnose synovial, labral and articular cartilage pathologies and subtle pathologies of femoral head and adjacent soft tissue. 4 Femoro-acetabular impingement (FAI) is another condition where MRI is useful to detect early changes in tissues before labral tear and cartilage delamination. ...
... Occult fractures have been reported to be as common as 3-10% among all normal radiographic findings obtained for trauma [5][6][7]. In patient cohorts with normal radiographic findings and ongoing clinical concern about fracture, the incidence of proximal femoral fracture is 7-40% when MRI is used as the reference standard [5,[7][8][9][10]. ...
... Magnetic resonance imaging (MRI) with its excellent soft tissue contrast and resolution with no operator dependence and no ionizing radiation is the imaging modality of choice for evaluation of hip joint abnormalities. 2 MRI offers valuable information regarding occult bony and cartilage injury such as stress fractures, avascular necrosis, and osteoarthritis, as well as soft tissue abnormalities such as muscle tears and bursitis. 3 MRI provides a useful assessment of patients in whom a femoro-acetabular impingement is clinically suspected. A high resolution non arthrographic technique can provide preoperative information regarding the presence and anatomic site of labral and cartilage abnormalities as well as MRI is an excellent method of preoerative assessment and helps guide the surgeon as to the likely site of labral and chondral abnormalities. ...
BACKGROUND & OBJECTIVES: Hip pain has different etiologies in adults and children. MRI is the method of choice in characterizing the various disorders and assessing the full extent of osseous, chondral and soft tissue abnormality of the hip joint. This study was aimed to evaluate the diagnostic value of MRI in assessment of painful hip joint.
... 9,15,22 Evidence supports the use of MRI as the modality of choice for the diagnosis of occult hip fracture with a sensitivity of 97-100%. 11,17,18,19,20,21 Diagnostic algorithms for hip fracture assessment do exist in the literature. Cannon et al developed an algorithm stratifying fracture risk by the energy level of the trauma and risk factors for osteoporosis. ...
Missing the diagnosis of hip fracture can be devastating. However, it is
often unclear to what extent a provider should pursue imaging when
evaluating the older adult with low-energy hip trauma, particularly in cases in
which initial plain radiographs are negative. We sought to develop an
algorithm based on available evidence to guide decision-making in such a
scenario.
... Also it allows clear differentiation of the individual component of the normal joint from one another. In addition, MRI allows identification of the bone marrow, cortex, muscles, fascia, nerves and vessels with high contrast between these structures [4] . ...
Background: Painful hip is a common problem in absence of a known acute trauma. MRI is a method of choice in detection of different causes of hip pain causing hip joint disability in adults including osseous, chondral and soft tissue abnormalities.
... While MRI is regarded as the best available secondary imaging modality to detect a missed hip fracture [18][19][20] lack of resources and out of hours access make this unfeasible, particularly with an increasing elderly population. Multidetector (MD) MDCT is available 24 h in many hospitals and can offer rapid imaging acquisition, which is particularly advantageous in a potentially cognitively impaired imaging cohort that is usually in considerable pain. ...
Aim
There is an increasing incidence of hip fracture with associated morbidity and mortality making accurate and timely diagnosis essential. The aim of this study was to compare computed tomography (CT) and magnetic resonance imaging (MRI) to ascertain the optimum second-line investigation in cases where plain radiograph is not diagnostic.
Material and Methods
Using the radiology information system, a total of 168 patients were identified with the suspected occult neck of femur fractures over 24 months who had undergone CT or MRI as second-line investigation. All relevant imaging was reviewed and diagnosis, any third-line or follow-up imaging was documented.
Results
About 16% of patients undergoing CT as second-line test had proven originally occult femoral neck fractures on plain radiograph compared with 13% of those having MRI. About 13% of patients underwent MRI following CT and in 1/13 case MRI detected an occult fracture that had not been detected on CT. The remaining 11 patients were either negative or MRI proved CT suspicions of fracture when extra diagnostic certainty was requested by the surgeons. CT detected more non femoral pelvic fractures 47% versus 37%.
Conclusion
CT and MRI are comparable at detecting occult femoral neck fractures. Given the increased availability, improved patient tolerance and speed of CT imaging, we advocate its use as the main second-line imaging modality. MRI remains a valuable problem-solving tool in a select few cases following review with a musculoskeletal radiologist.
... Also it allows clear differentiation of the individual component of the normal joint from one another. In addition, MRI allows identification of the bone marrow, cortex, muscles, fascia, nerves and vessels with high contrast between these structures [4] . ...
... Occult fractures have been reported to be as common as 3-10% among all normal radiographic findings obtained for trauma [5][6][7]. In patient cohorts with normal radiographic findings and ongoing clinical concern about fracture, the incidence of proximal femoral fracture is 7-40% when MRI is used as the reference standard [5,[7][8][9][10]. ...
OBJECTIVE. The objective of our study was to compare ultrasound (US) tophus and monosodium urate (MSU) deposit detection and US tophus size in the metatarsophalangeal (MTP) 1 joint with dual-energy CT (DECT) using two DECT postprocessing protocols in patients presenting with podagra. SUBJECTS AND METHODS. Seventy-five consecutive patients with podagra (66 men and nine women; mean age, 65.6 years; age range, 33-88 years) and 75 control subjects with MTP 1 joint osteoarthritis (49 men and 26 women; mean age, 63.0 years; age range, 35-87 years) prospectively underwent US and DECT between 2016 and 2018 to assess the MTP 1 joint. Two Syngovia postprocessing DECT protocols with different minimum attenuation thresholds of 150 HU (DECT 150 protocol) versus 120 HU (DECT 120 protocol) and the same maximum attenuation threshold (500 HU) and constant kilovoltage setting of tubes A and B at 80 and 140 kVp were evaluated. Interobserver variability of the two DECT protocols was calculated and compared with that of US. RESULTS. The postprocessing DECT 150 protocol was positive for tophus detection in 55 of 75 patients (73.3%) with podagra, whereas the postprocessing DECT 120 protocol detected MSU deposits in all 75 patients (100%). Tophus size assessed using the DECT 120 protocol showed an improved correlation with tophus size detected on US (p < 0.01). Interobserver variability of DECT was improved when using the DECT 120 protocol (p < 0.01). CONCLUSION. The postprocessing DECT 120 protocol enables improved visualization of MSU deposits and provides more accurate information about tophus size that better correlates with tophus size on US compared with the standard postprocessing DECT 150 protocol.
... Occult fractures have been reported to be as common as 3-10% among all normal radiographic findings obtained for trauma [5][6][7]. In patient cohorts with normal radiographic findings and ongoing clinical concern about fracture, the incidence of proximal femoral fracture is 7-40% when MRI is used as the reference standard [5,[7][8][9][10]. ...
OBJECTIVE. The purpose of this study was to assess the diagnostic performance of CT for detection of occult proximal femoral fracture. MATERIALS AND METHODS. A systematic search adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed for studies of the sensitivity and specificity of CT for detection of hip fracture. Two independent investigators extracted data and assessed the quality of each study using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). A qualitative systematic review and quantitative meta-analysis were performed. A Bayesian bivariate random effects meta-analysis model with integrated nested Laplace approximation was used to estimate sensitivity and specificity. RESULTS. Thirteen heterogeneously reported studies were assessed that included 1248 patients (496 with a hip fracture and 752 without) with MRI or clinical follow-up as the reference standard. There were 50 false-negative examinations. The summary estimate of sensitivity was 94% and of specificity was 100%. CONCLUSION. CT can be considered a reasonable choice when occult proximal femoral fracture is suspected clinically in patients for whom MRI is contraindicated or not readily available. However, for patients with ongoing clinical concern about hip fracture despite normal CT findings, MRI should be performed.
... replacement disorders, musculoskeletal neoplasms, and osteomyelitis involving the hip. 1,2 Because of the presence of different operative approaches and treatment strategies for different hip pathologies, accurate preoperative diagnosis became a very important goal. With the limited utility of CT scan in the differential diagnosis of various hip pathologies, MRI is generally the investigation of choice in characterization of them. ...
BACKGROUND
Magnetic Resonance Imaging (MRI) has been one of the most spectacular advances in medicine and has practically
revolutionized the diagnosis of hip pathologies. This acceptance was initially due to its high sensitivity and specificity in detection
of avascular necrosis of the femoral head. Since then however, MR imaging has also proved efficacious in the evaluation of
primary musculoskeletal tumours, arthropathies, trauma, marrow replacement processes and osteomyelitis.
The objective of the study is to study usefulness of MRI in patients presenting with symptoms suggestive of hip pathologies.
MATERIALS AND METHODS
It was a cross-sectional study carried out in a tertiary care institute from July 2015 to November 2017. A total of 80 cases with
hip pathology attending Orthopaedics OPD participated in the study. There were bilateral hip pathologies in 27 patients, so a
total of 107 pathological hips were studied. All the participants were subjected to MRI scan.
RESULTS
In present study, painful hip was the most common presenting symptom in 95% followed by restricted movement - 89% and
gait abnormality-79%. Avascular necrosis (AVN) femoral head was the most common pathology detected comprising 33 of the
80 cases (66%). The next most common abnormality detected was infective arthritis (25%). Bone tumours together comprise
11% of patients. Three patients of sacroiliitis were included in the study because they presented with hip pain.
CONCLUSION
MRI showed exquisite sensitivity in detecting bone marrow oedema, cartilage, labrum, synovium, joint effusion, necrosis as well
as extension of the tumours. With MRI, one can stage the hip pathology to prognosticate and influence therapeutic decisions.
... Furthermore, it was noted that for patients whom had their MRI scans done within 48 hours, senior radiologists achieved up to 100% accurate results. 17 Given these findings, the authors suggest that in the clinical setting of a suspected occult fracture of the hip, physicians should obtain MRI scans early and both the proximal femur and acetabulum regions should be inspected carefully to ensure no occult fracture is missed. Other significant soft tissue injuries should also be identified. ...
Dear Editor, Occult acetabular fractures are uncommon injuries. 1 Whilst acetabular fractures are often the result of high-energy trauma, 2 injuries of varying energy may result in occult acetabular fractures. In the elderly with osteoporosis, they can present with such fractures from low-energy injuries 3 or even in situations with no discernible history of trauma. The elderly may also present with pre-existing arthritis of the hip joint and this can confound the clinical presentation of an occult acetabular fracture. In patients with persistent hip pain especially on weight-bearing, radiographic imaging is indicated. Despite the efficacy of radiographs in the detection of acetabular fractures, occult acetabular fractures are not visible on radiographs and require further imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) scans for diagnosis. 4,5 In addition, advanced imaging can serve to differentiate exacerbated arthritic pain from that of an occult fracture. Occult acetabular fractures are often not displaced and therefore non-surgical treatment can be considered. For the purpose of this review, we defined occult acetabular fractures to be those that cannot be diagnosed with plain radiographs (including specialised radiograph views such as Judet's view), even on retrospective viewing. We describe 3 cases of occult acetabular fractures in the elderly (65 years and above) as a result of varying mechanisms of injury and reviewed existing literature. Of the 15 cases of occult acetabular fractures found in existing literature, only 10 met our definition (Table 1). The remaining 5 fractures were seen on retrospective viewing of initial radiographs. These injuries are often difficult to diagnose and require a high degree of suspicion as well as judicious use of advanced imaging. This paper thus seeks to discuss the clinical presentation, imaging findings, treatment modalities and outcomes of occult acetabular fractures. Case Reports Case 1 An 82-year-old male with hypertension and hyperlipidaemia presented with sudden onset of left hip pain for 2 days. Prior to presentation, the patient was community-ambulant without aid. There was no history of trauma. The hip pain occurred on weight-bearing but resolved on rest. On examination, there was full range of motion of the left hip. Axial loading reproduced the pain. Pelvic and hip radiographs (Fig. 1a) did not reveal any fractures. In view of the persistent pain, an MRI of the left hip (Fig. 1b) was performed on post admission day 2. The MRI revealed a non-displaced fracture of the anterior column of the left acetabulum. His bone mineral density was measured using dual energy X-ray absorptiometry (DEXA), which showed a T-score of-2.3 (femur) and-0.6 (lumbar spine). His vitamin D levels were low at 17.7 g/dl. As the acetabular fracture was non-displaced and over a non-weight-bearing portion of the acetabulum, the patient was treated non-surgically. He was advised not to weight bear on the left lower limb for 1 month. A Judet's view of his pelvis (Figs. 1c and 1d) was performed 1 month after the MRI of his pelvis and since no definite fracture line was seen, he was subsequently allowed to weight bear as tolerated. For his osteopaenia, he was treated with vitamin D replacement and bisphosphonate therapy. One year after the injury, the patient was well and ambulating without aid. Case 2 A 65-year-old lady with multiple comorbidities such as diabetes mellitus type 2, hypertension, hyperlipidaemia and hypothyroid on thyroxine replacement, presented to the emergency department after a road traffic accident. She was the front seat passenger of a car that collided into a pillar. After the accident, the patient complained of persistent left hip pain. Whilst she was still able to ambulate, the hip pain was exacerbated on weight-bearing. On examination, there was full range of motion of the left hip. There was palpable tenderness over the posterior aspect of the left hip. Pelvic radiographs did not reveal any fractures. An MRI of her left hip (Fig. 2a) showed a non-displaced fracture of the posterior column of the acetabulum and a non-displaced Pipkin classification type IV femoral head fracture. She was managed non-surgically with wheelchair mobilisation. At the 2-month follow-up, the pelvic radiograph (Fig. 2b) showed sclerosis over the posterior acetabulum, suggestive of a healing fracture. She eventually recovered fully and was able to ambulate independently. Occult Acetabular Fractures-Marcus J Lee et al Letter to the Editor
... 74,75 Diagnostic delay of hip fracture can lead to avascular necrosis, nonunion, increased pain and mortality risk, and greater risk of thromboembolic complications. 76,77 The decision on the preferred modality may depend on clinical and operative aims, suspicion for alternative abnormality, timeliness, patient claustrophobia, and resource availability. 78 Access to any modality should not cause a delay in diagnosis and treatment. ...
A comprehensive geriatric assessment, combined with a battery of imaging and blood tests, should be able to identify those hip fracture patients who are at higher risk of short- and long-term complications. This comprehensive assessment should be followed by the implementation of a comprehensive multidimensional care plan aimed to prevent negative outcomes in the postoperative period (short and long term), thus assuring a safe and prompt functional recovery while also preventing future falls and fractures.
... A truly occult fracture is defined as clinical symptoms or signs of fracture without radiographic evidence (12,13). Occult and suspect hip fractures may be further investigated by MRI (17)(18)(19)(20)(21)(22)(23) or by CT (5,10,(24)(25)(26)(27)(28)(29). Modern CT, especially when viewed with a soft tissue window width/level setting of about 400/40 (26), has the ability to evaluate bone marrow edema and lipohemarthrosis and has a diagnostic capability approaching that of MRI (26,28,29). ...
Background
A thorough quality analysis of radiologic performance is cumbersome. Instead, the prevalence of missed cervical hip fractures might be used as a quality indicator.
Purpose
To validate a computer-based quality study of cervical hip fracture radiography.
Material and Methods
True and false negative and positive hip trauma radiography during 6 years was assessed manually. Patients with two or more radiologic hip examinations before surgery were selected by computer analysis of the databases. The first of two preoperative examinations might constitute a missed fracture. These cases were reviewed.
Results
Out of 1621 cervical hip fractures, manual perusal found 51 (3.1%) false negative radiographic diagnoses. Among approximately 14,000 radiographic hip examinations, there were 27 (0.2%) false positive diagnoses. Fifty-seven percent of false negative reports were occult fractures, the other diagnostic mistakes. There were no significant differences over the years. Diagnostic sensitivity was 96.9% and specificity 99.8%. Computer-assisted analysis with a time interval of at least 120 days between the first and the second radiographic examination discovered 39 of the 51 false negative reports.
Conclusion
Cervical hip trauma radiography has high sensitivity and specificity. With computer-assisted analysis, 76% of false negative reports were found.
... A significant amount of orthopaedic admissions are due to hip fractures. These figures are expected to rise making hip fractures a major public health concern due to an ever increasing ageing population [4]. Due to the serious nature and complexity of hip fractures, this group of frail patients need to be promptly managed by a close multidisciplinary team of experts from many specialities. ...
Non-displaced hip fractures can be difficult to diagnose on plain film radiographs. When there is ongoing clinical suspicion of an occult fracture, further imaging is obtained. We investigated the sensitivity of computed tomography (CT) scans in detecting these fractures and the delays to surgery that three-dimensional imaging causes. We identified 78 CT scans performed for possible hip fractures over the past 3 years with the presence and absence of a fracture recorded. Based on subsequent imaging, the accuracy of CT scans was determined. CT scanning yielded sensitivity was 86% and specificity 98% for occult hip fracture (OHF). The median delay to definitive diagnosis was 37 h. Our results demonstrate that CT scan does not bear sufficient sensitivity to detect all OHFs. We therefore recommend that MRI should be offered when a fracture is suspected. CT scans should be reserved for when MRI is not available, but a negative scan should be confirmed with subsequent MRI.
Background
In high-energy femoral shaft fractures (FSFs), ipsilateral femoral neck fractures (FNFs) can be missed by conventional trauma computed topography (CT) imaging, resulting in increased treatment costs and patient complications. Preliminary evidence suggests that a rapid, limited-sequence pelvis and hip magnetic resonance imaging (MRI) protocol can identify these occult fractures and be feasibly implemented in the trauma setting. This study aims to establish the economic break-even point for implementing such an MRI protocol in all high-energy FSFs.
Methods
We used an adapted break-even economic tool to determine whether the costs of a targeted MRI protocol can be offset by cost-savings achieved through prevention of missed fractures (thus avoiding prolonged admission and re-operation). Sensitivity analyses were performed to demonstrate reliability of the economic modelling across a range of assumptions.
Results
Assuming a baseline of FNFs missed on CT of 12%, an MRI cost of £129 and cost of treating each missed FNF of £2457.5, the equation yielded a break-even rate of 7% and absolute risk reduction (ARR) of 5%, indicating that for every 100 FSFs, MRI would need to diagnose 5 of the 12 missed FNF to be economically viable (number needed to treat (NNT)=20). Economic viability was maintained even at double the cost of MRI, while increasing the cost of treating each complication served to reduce the ARR further, increasing cost-savings.
Conclusion
A rapid, limited-sequence MRI protocol to exclude occult ipsilateral FNFs in all high-energy FSFs appears to be economically justified measure. Further research exploring the feasibility of such a protocol, as well as the role of intra-operative fluoroscopy in this context, is required.
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.
Radiography is a standard diagnostic test for horses with suspected fractures of the palmar/plantar processes (PP) of the distal phalanx, however published studies evaluating the diagnostic utility for radiography are currently lacking. The objectives of this retrospective, diagnostic case‐control study were to determine the sensitivity of radiographs for the detection of PP fractures, and determine the diagnostic utility of the palmar/plantar oblique projections of the PP for the identification of PP fractures compared to standard radiographic series. The medical records of horses undergoing MRI examination were reviewed and 23 horses diagnosed with a PP fracture were included as cases for analysis. Forty‐six control horses were selected. Radiographs, including palmar/plantar oblique (palmaro/plantaro50o‐proximal 45o‐medial(lateral)‐dorsodistolateral (medial) oblique (PPrM(L)‐DDiL(M)O) projections, and MRI images were assessed independently for the presence or absence of PP fractures and the sensitivity and specificity of radiographs for their detection were calculated, using MRI as the gold‐standard. A second, blinded, radiographic evaluation excluding the palmar/plantar oblique views was performed. Twenty‐seven PP fractures were identified in the 23 case horses on MRI examination. Twenty‐two fractures were identified in 20/23 horses on examination of the full radiographic series (sensitivity and specificity of 81.5% and 100% respectively). Fractures were most frequently identified on the palmar/plantar oblique projections (19/22 fractures), followed by the lateromedial projection. Radiographic assessment excluding the palmar/plantar oblique projections identified 18 PP fractures in 16/23 horses. Careful assessment of a standard radiographic series of the foot will allow identification of PP fractures but palmar/plantar oblique projections will improve the detection of these fractures.
Background
Hip pain is a common presentation to the Emergency Department, with a wide spectrum of underlying causes. Spontaneous iliopsoas tendon rupture (ITPR) is an uncommon cause of atraumatic hip pain in the elderly.
Results
We describe the case of a 94-year-old female who presented with sequential bilateral spontaneous ITPR confirmed on Magnetic Resonance Imaging (MRI). This patient was managed conservatively with analgesia and physiotherapy, with significant improvement in symptoms and mobility.
Conclusions
IPTR should be considered in the adult with atraumatic hip pain to ensure prompt diagnosis and appropriate treatment. It appears to respond well to conservative treatment.
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.
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.
OBJECTIVE. This systematic review and meta-analysis aimed to evaluate the diagnostic accuracy of limited MRI protocols for detecting radiographically occult proximal femoral fractures. MATERIALS AND METHODS. A systematic review of MEDLINE, Embase, Scopus, the Cochrane Library, and the gray literature through November 15, 2019, was performed. Original articles with 10 or more patients evaluating limited MRI protocols for the diagnosis of radiographically occult proximal femoral fractures compared with multiparametric MRI with or without clinical outcome as the reference standard were included in the analysis. Patient, clinical, MRI, and performance parameters were independently acquired by two reviewers. Meta-analysis was performed using a bivariate mixed-effects regression model. RESULTS. Eleven studies with 938 patients and 247 proximal femoral fractures met inclusion criteria, and five of these studies were included in the meta-analysis. The pooled and weighted summary sensitivity and specificity and the area under the summary ROC curve for limited MRI protocols in detecting radiographically occult hip fractures were 99% (95% CI, 91-100%), 99% (95% CI, 97-100%), and 1 (95% CI, 0.99-1), respectively. The aggregate sensitivity and specificity values for a single-plane T1-weighted sequence only, STIR sequence only, T1-weighted and STIR sequences, and T2-weighted sequence only were as follows: 97% (89/92) and 100% (76/76), 99% (126/127) and 99% (865/873), 100% (118/118) and 99% (867/874), and 86% (51/59) and 97% (137/141), respectively. Sensitivity was 100% (58/58) when images were acquired on 3-T scanners only and 99% (284/288) when interpreted only by certified radiologists. The mean scanning time for the limited MRI protocols was less than 5 minutes. CONCLUSION. Limited MRI protocols can be used as the standard of care in patients with a suspected but radiographically occult hip fracture. A protocol composed of coronal T1-weighted and STIR sequences is 100% sensitive.
Recently, natural killer (NK)-based immunotherapy has attracted attention as a next-generation cell-based cancer treatment strategy due to its mild side effects and excellent therapeutic efficacy. Here, we describe multifunctional nanoparticles (MF-NPs) capable of genetically manipulating NK cells and tracking them in vivo through non-invasive magnetic resonance (MR) and fluorescence optical imaging. The MF-NPs were synthesized with a core-shell structure by conjugation of a cationic polymer labeled with a near-infrared (NIR) fluorescent molecule, with the aid of a polydopamine (PDA) coating layer. When administered to NKs, the MF-NPs exhibited excellent cytocompatibility, efficiently delivered genetic materials into the immune cells, and induced target protein expression. In particular, the MF-NPs could induce the expression of EGFR targeting chimeric antigen receptors (EGFR-CARs) on the NK cell surface, which improved the cells' anti-cancer cytotoxic effect both in vitro and in vivo. Finally, when NK cells labeled with MF-NPs were injected into live mice, MF-NP-labeled NK cells could be successfully imaged using fluorescence and MR imaging devices. Our findings indicate that MF-NPs have great potential for application of NK cells, as well as other types of cell therapies involving genetic engineering and in vivo monitoring of cell trafficking.
Background
Magnetic resonance imaging is one of the diagnostic tools that uses magnetic particles as contrast agents. It is noninvasive methodology which provides excellent spatial resolution. Although magnetic resonance imaging offers great temporal and spatial resolution and rapid in vivo images acquisition, it is less sensitive than other methodologies for small tissue lesions, molecular activity or cellular activities. Thus, there is a desire to develop contrast agents with higher efficiency. Contrast agents are known to shorten both T1 and T2. Gadolinium based contrast agents are examples of T1 agents and iron oxide contrast agents are examples of T2 agents. In order to develop high relaxivity agents, gadolinium or iron oxide-based contrast agents can be synthesized via conjugation with targeting ligands or functional moiety for specific interaction and achieve accumulation of contrast agents at disease sites.
Main body
This review discusses the principles of magnetic resonance imaging and recent efforts focused on specificity of contrast agents on specific organs such as liver, blood, lymph nodes, atherosclerotic plaque, and tumor. Furthermore, we will discuss the combination of theranostic such as contrast agent and drug, contrast agent and thermal therapy, contrast agent and photodynamic therapy, and neutron capture therapy, which can provide for cancer diagnosis and therapeutics.
Conclusion
These applications of magnetic resonance contrast agents demonstrate the usefulness of theranostic agents for diagnosis and treatment.
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.
Purpose:
The purpose of this study was to evaluate the diagnostic performance of CT for assessment of occult fractures of the proximal femur, pelvis, and sacrum.
Materials and methods:
A retrospective review was performed on patients who received a CT of the hip or pelvis for suspected occult fracture after negative or equivocal radiographs performed within 24 h. The official radiology report was utilized for the determination of CT findings and calculation of sensitivity and specificity. Surgical reports, MRI reports, and clinical follow-up were used as the standard of reference. Sensitivity and specificity were calculated with 95% confidence intervals.
Results:
Seventy-four patients received CT of the hip or pelvis for clinical concern for occult fracture after negative or equivocal radiographs. By the reference standard, a total of 40 fractures were present in 25/74 (33.8%) patients, including 35 conservatively treated fractures of the greater trochanter, pelvis, and sacrum, and 5 operatively treated proximal femoral fractures. A total of 14/74 (18.9%) of patients had an MRI within 1 day of CT. MRI identified an operatively treated femoral neck fracture not seen on CT and an operatively treated intertrochanteric fracture, which CT described as a greater trochanteric fracture. There were two false negative conservatively treated pelvic fractures not seen on CT but diagnosed on MRI. On a per-patient basis, CT had an overall sensitivity of 88% (22/25; 95% confidence intervals 69-97%), specificity of 98% (48/49; 95% confidence intervals 89-100%), and negative predictive value of 94%. For the five operative proximal femoral fractures, the sensitivity of CT was 60% (3/5; 95% confidence intervals 15-95%), specificity was 99% (68/69; 95% confidence intervals 92-100%), and negative predictive value was 97%.
Conclusions:
In the clinical setting of suspected occult fracture, the sensitivity of clinical CT reports for detection of any type of fracture of the proximal femur, pelvis, or sacrum was 88%. For the small number of operatively treated proximal femoral fractures seen in the study, sensitivity of CT was 60% (3/5) and negative predictive value was 97%, although the relatively few patients needing fixation precludes statistical analysis.
Background Clinical question Comment References
Introduction:
Hip fractures are commonly diagnosed by plain radiography. When a patient presents with negative radiographs and high clinical suspicion of fracture, guidelines recommend proceeding with magnetic resonance imaging (MRI) to diagnose the patient. The aim of this study was to assess the use of MRI in diagnosing hip fractures following trauma to the hip and describe clinical outcome after MRI-diagnosed hip fractures. The perspective was to develop new recommendations for MRI use.
Materials and methods:
616 patients at a university hospital fulfilled the inclusion criteria of having an MRI scan of the hip following trauma between the years of 2005 and 2014. Data was collected from the patients' medical records.
Results:
The annual number of MRIs increased over the ten-year period. Out of 616 MRI scans 228 (37%) showed fracture of the hip with a dominance of trochanteric fractures, 185 (30%) revealed pelvic fracture and 183 (29%) were negative. No patient with acute pelvic fracture had associated fracture of the hip. The main reason to proceed with MRI was a strong clinical suspicion of fracture in patients with negative initial radiographs. Amongst the 228 patients with fracture, 187 (82%) were treated operatively. Of patients with hip fracture, 90 (39%) patients suffered a general complication and 11 (5%) had hip complications. The complication rate of patients with fracture on MRI was compared to that of a cohort of general hip fracture patients at our hospital. No significant difference in twelve months' survival or general complications could be found, but the MRI group had a significantly lower hip complication rate.
Conclusion:
The diagnosis set by MRI, with high share of pelvic fractures or no fracture, reflects the difficulty in differential diagnosing this group of patients. The rate of occult hip fractures was low and patients with pelvic fractures already known from X-ray did not have additional hip fractures. We found an increase in the annual number of MRIs during the 10-year-period. MRI-diagnosed hip fracture patients do not suffer more complications than the regular hip fracture patient.
We synthesized core-shell structured Fe/G-PEG NPs composed of an Fe core and a PEGylated graphene, which exhibited superior stability against oxidation, good water dispersity, low cytotoxicity and high magnetic performance. These advantages ensure them as candidates for ultra-sensitive contrast enhanced magnetic resonance imaging agents in vivo.
Study objective:
Hip fractures cause significant morbidity and mortality. Determining the optimal diagnostic strategy for the subset of patients with potential occult hip fracture remains challenging. We determined the most cost-effective strategy for the diagnosis of occult hip fractures from the choices of performing only computed topography (CT), performing only magnetic resonance imaging (MRI), performing CT and if negative performing MRI (MRI selective strategy), or discharging the patient without advanced imaging.
Methods:
We developed a decision-analytic model to compare outcomes and costs of different diagnostic strategies for the diagnosis of an occult hip fracture from a societal perspective. Model inputs were derived from charge data, Medicare reimbursements, and the literature. Strategies with an incremental cost-effectiveness ratio (ICER) below $100,000 per quality-adjusted life-year (QALY) gained were considered cost-effective. We tested the robustness of our results using probabilistic sensitivity analysis.
Results:
Compared to a CT strategy, MRI provides an additional 0.05 QALY at an incremental cost of $1,227 and ICER of $25,438/QALY. For facilities without MRI capability, if the cost of transfer is below $1228, transferring the patient to a MRI-capable facility is the most cost-effective strategy. Above this cost, employing a CT and if negative transfer to a MRI-capable facility strategy was more cost-effective. When the cost of a transfer reached more than $4,039, it became more cost-effective to only obtain a CT.
Conclusion:
MRI is a cost-effective strategy for the diagnosis of an occult hip fracture. For facilities without MRI capability, the most cost-effective strategy depends on the cost of the interfacility transfer. This article is protected by copyright. All rights reserved.
The purpose of this study was to prospectively assess the independent effect of hip fracture on mortalìty, hospitalization, and functional status.
Among 7527 members of the Longitudinal Study of Aging who were over age 70 at baseline, 368 persons with hip fracture occurring between 1984 and 1991 were identified. Median length of follow-up was 831 days.
Hip fracture was significantly related to mortality (adjusted hazards ratio [AHR] = 1.83; 95% confidence interval [CI] = 1.55, 2.16) when treated as a time-dependent covariate. This effect was concentrated in the first 6 months postfracture (AHR = 38.93, 95% CI = 29.58, 51.23, vs AHR = 1.17; 95% CI = 0.95, 1.44). Hip fracture significantly increased the likelihood of subsequent hospitalization (adjusted odds ratio = 3.31, 95% CI = 2.64, 4.15) and increased the number of subsequent episodes by 9.4%, the number of hospital days by 21.3%, and total charges by 16.3%. Hip fracture also increased the number of functional status dependencies.
The health of older adults deteriorates after hip fracture, and efforts to reduce the incidence of hip fracture could lower subsequent mortality, morbidity, and health services use.
This review examines all pertinent literature sources published in the English language between 1966 to the present concerning hip fracture epidemiology, hip fracture injury mechanisms, and hip fracture management strategies. These data reveal hip fractures have several causes, but among these, the impact of falls and muscle weakness, along with low physical activity levels seems to be the most likely explanation for the rising incidence of hip fracture injuries. Related determinants of suboptimal nutrition, drugs that increase fall risk and lower the safety threshold and comorbid conditions of the neuromuscular system may also contribute to hip fracture disability. A number of interventions may help to prevent hip fracture injuries, including, interventions that optimize bone mass and quality, interventions that help prevent falls and falls dampening interventions. Rehabilitation outcomes may be improved by comprehensive interventions, prolonged follow-up strategies and ensuring that all aging adults enjoy optimal health.
The relationship between osteoarthritis and osteoporosis (hip fracture) was studied using the data from the MEDOS study, a large prospective epidemiological study of femoral neck fracture patients and age-matched controls in the Mediterranean area. Osteoarthritis was found to be protective against hip fracture in both men and women, with a significant reduction of the relative risk factor for osteoporosis (relative risk = 0.48 and 0.68, respectively, p < 0.001). The age-adjusted relative risk factor for osteoporosis remains even after adjustment for body mass index, indicating that body mass index and osteoarthritis are independent relative risk factors for hip fracture. The mean age of the group with co-existent osteoarthritis and hip fracture was significantly higher for both men and women, compared to the group with osteoporosis alone. This indicates that if osteoarthritic subjects develop osteoporotic fracture, they do so at a later age. The osteoarthritic cases compared to controls and hip fracture cases were significantly smaller in stature in both sexes, and women had a significantly higher body weight and body mass index. Extra-capsular hip fracture was significantly more frequent in cases with concomitant osteoarthritis. These findings confirm earlier observations that osteoarthritis and osteoporosis are two distinct diseases and not phenomena related solely to ageing.
Hip fractures are recognized to be a major public health problem in many Western nations, most notably those in North America, Europe and Oceania. Incidence rates for hip fracture in other parts of the world are generally lower than those reported for these predominantly Caucasian populations, and this has led to the belief that osteoporosis represents less of a problem to the nations of Asia, South American and Africa. Demographic changes in the next 60 years, however, will lead to huge increases in the elderly populations of those countries. We have applied available incidence rates for hip fracture from various parts of the world to projected populations in 1990, 2025 and 2050 in order to estimate the numbers of hip fractures which might occur in each of the major continental regions. The projections indicate that the number of hip fractures occurring in the world each year will rise from 1.66 million in 1990 to 6.26 million by 2050. While Europe and North America account for about half of all hip fractures among elderly people today, this proportion will fall to around one quarter in 2050, by which time steep increases will be observed throughout Asia and Latin America. The results suggest that osteoporosis will truly become a global problem over the next half century, and that preventive strategies will be required in parts of the world where they are not currently felt to be necessary.
From a series of 825 consecutive admissions with a hip fracture there were 16 cases in which the diagnosis was not made when the patient was initially seen in hospital. The reason for the delay in diagnosis was failure to correctly interpret X-rays in 10 cases and failure to X-ray the hip in three cases. The fracture was radiologically invisible in only three patients. Fifteen of the fractures were initially undisplaced, but as a consequence of the delay in diagnosis displacement occurred in 75% of subcapital fractures and all extracapsular fractures.
To determine the frequency of unsuspected pelvic fracture and soft-tissue injury in patients referred for magnetic resonance (MR) imaging for possible radiographically occult hip fracture.
Seventy patients with symptoms of possible hip fracture but negative plain radiographs were evaluated with MR imaging. Large-field-of-view T1-weighted coronal images were obtained, and additional T2-weighted or short inversion time inversion recovery (STIR) sequences were used. The number of soft-tissue and bone injuries identified was recorded.
Eighty percent of patients had bone or soft-tissue abnormalities. Occult femoral and pelvic fractures were demonstrated in 37% and 23% of patients, respectively. Soft-tissue abnormalities were noted in 74% of patients. When a proximal femoral fracture was not present, MR imaging revealed a 27% frequency of occult pelvic fracture and a 50% frequency of bone or soft-tissue abnormality.
A high prevalence of occult pelvic fracture and soft-tissue injury may be identified with MR studies designed to evaluate occult hip fracture when large-field-of-view T1-weighted coronal sequences are combined with T2-weighted or STIR sequences.
Establishing the diagnosis of a non-displaced hip fracture in an elderly patient can be a prolonged and costly procedure, involving hospital admission, several days of bed rest, and a bone scan 3 to 5 days later. The authors evaluated 10 hips in 10 patients with a questionable diagnosis of non-displaced hip fracture. Magnetic resonance imaging (MRI) soon after admission revealed four patients with acute hip fractures who were subsequently treated. The other six patients, whose scans were negative for either femoral neck or intertrochanteric fractures, were mobilized. The authors show that, through the use of an immediate MRI study of a questionable hip fracture, the prolonged recumbency and inherent costs associated with awaiting a positive bone scan can be avoided.
Hip fractures lead to excess deaths and substantial disability. Most are related both to falls and to osteoporosis, which affects one in four post-menopausal white women, but a lesser number of men or women of other races. Consequently, about half of the 1.66 million hip fractures worldwide in 1990 occurred in Europe and North America. Even within these regions, however, there is substantial variation in hip fracture incidence rates, which suggests the existence of important environmental factors that could be manipulated to reduce hip fracture occurrence. This is important because in the United States alone, a quarter of a million hip fractures annually cost over $8 billion, mostly for acute medical care and nursing home services. Future costs will be even greater because populations are ageing rapidly around the world and because hip fracture incidence rates are rising in some regions. The number of elderly is increasing most rapidly in Asia, Latin America, the Middle East, and Africa, and these regions will account for over 70% of the 6.26 million hip fractures expected in the year 2050. Because fracture treatment is expensive, and rehabilitation not always successful, effective prophylaxis offers the only hope of alleviating the enormous social burden of hip fractures.
Sixty-two consecutively seen patients in whom a fracture about the hip was clinically suspected, but in whom the radiographic findings were negative, were examined with both magnetic resonance imaging and bone-scanning. The magnetic resonance-imaging studies, consisting of T1-weighted coronal sections, were done within twenty-four hours after admission to the hospital, and the bone scans, within seventy-two hours after admission. There were twenty-three men and thirty-nine women. Thirty-six patients who had evidence of a fracture on the magnetic resonance-imaging study also had a positive bone scan initially. Twenty-three patients who had a negative finding on the magnetic resonance-imaging study had a corresponding negative bone scan. Two additional patients had evidence of avascular necrosis of the femoral head on both the magnetic resonance image and the bone scan, and they were managed non-operatively. One patient had a positive magnetic resonance image and a negative bone scan twenty-four hours after admission. A repeat bone scan, which was made six days later, was positive for a fracture of the femoral neck and the patient was managed with internal fixation. Magnetic resonance imaging was as accurate as bone-scanning in the assessment of occult fractures of the hip. The magnetic resonance imaging took less than fifteen minutes to perform, and it was tolerated well by the patient. Magnetic resonance imaging provides an early diagnosis of occult fractures about the hip and may decrease the length of the stay in the hospital by expediting definitive treatment.
Around 40% of white women and 13% of white men in the United States have at least one fragility fracture after the age of 50 years. The risk of fracture increases with advancing age and progressive loss of bone mass, and varies with the population being considered. The age-adjusted incidence of fragility fractures in both sexes is 25% lower in Britain and many areas of Europe than in the United States. Mortality 5 years after hip or vertebral fracture is about 20% in excess of that expected; mortality rate is highest in men > 75 years suffering from a variety of chronic diseases. Most excess deaths occur in the first 6 months after hip fracture. One year after hip fracture, 40% of patients are still unable to walk independently, 60% have difficulty with at least one essential activity of daily living, and 80% are restricted in other activities, such as driving and grocery shopping. Moreover, 27% of these patients enter a nursing home for the first time. Less is known of the epidemiology of vertebral fractures and of the associated mortality and morbidity. Although an estimated 30% of postmenopausal U.S. white women have osteoporosis, and 1 in 4 has at least one vertebral deformity, two thirds of vertebral fractures remain undiagnosed. After a clinically diagnosed vertebral fracture, survival rate decreases gradually from that expected without fracture. Women with severe vertebral deformities have a consistently higher risk of back pain and height loss. An accurate assessment of the risk of fractures associated with osteoporosis and of their impact on quality of life is essential if appropriate and cost-effective interventions are to be designed for different populations.
To evaluate the cost-effectiveness of magnetic resonance imaging (MRI) compared with radionuclide bone scan in the evaluation of patients with clinically suspected hip fractures.
The medical records of all patients who had been seen in the emergency room over a 4 1/2 year period with a clinically suspected hip fracture, negative or equivocal plain films, and either a subsequent bone scan or MRI examination were retrospectively reviewed. The time to diagnosis, admission rate, and time to surgery were determined. A two-sample t-test was used to assess the statistical significance of the results. A theoretical cost analysis was performed using current charges to estimate all expenses.
Forty patients (11 male, 29 female; age 28-99 years) satisfied our inclusion criteria.
Twenty-one patients had bone scans (six with fractures), and 19 had MRI (four with fractures). The time to diagnosis was 2.24 +/- 1.30 days for bone scanning and 0.368 +/- 0.597 days for MRI (P < 0.0001). Twenty patients in the bone scan group were admitted compared with 13 in the MRI group. The time to surgery was at least 1 day longer in patients undergoing bone scanning. Bone scanning resulted in higher patient costs compared with MRI because of the delay in diagnosis. In the evaluation of patients with suspected hip fractures, early MRI is more cost-effective than delayed bone scanning. Further prospective studies comparing the cost-effectiveness of early MRI with early bone scanning are needed.
The majority of fractures of the hip are readily diagnosed on the basis of the clinical findings and plain radiographs. When initial X-rays are negative or equivocal and a high clinical suspicion exists for an occult hip fracture, additional diagnostic studies need to be performed. Use of limited magnetic resonance imaging in the diagnosis of occult hip fracture upon initial presentation to the emergency department is reported. (Am J Emerg Med 1998;16:390-392. Copyright (C) 1998 by W.B. Saunders Company).
Acute hip fracture is among the most commonly encountered orthopedic injuries seen by the emergency physician. The majority of these fractures can be readily diagnosed on the basis of clinical findings and plain radiographs. When initial films are negative or equivocal, but a high clinical suspicion exists for a hip fracture, additional diagnostic studies need to be performed because significant morbidity can result from ambulation on an unrecognized fracture. The emergency physician needs to remain vigilant for this potential orthopedic pitfall. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency practitioner.
To compare MR imaging, radiography and bone scintigraphy in the diagnosis of stress injuries to bones of the pelvis and lower extremity.
Fifty consecutive conscripts with clinical signs of a stress injury to bone underwent MR imaging and bone scintigraphy. Forty-three patients also had radiographs available. Bone scintigraphy served as a gold standard.
Compared to the bone scintigraphy, the sensitivity of radiography was 56%, specificity 94%, accuracy 67%, positive predictive value (PPV) 95%, and negative predictive value (NPV) 48%. The kappa value for radiography and bone scintigraphy was fair (0.39). Correspondingly, the sensitivity of MR imaging was 100%, specificity 86%, accuracy 95%, PPV 93% and NPV 100%. The kappa value for MR imaging and bone scintigraphy was very good (0.89). MR imaging depicted 3 bone stress injuries that were not visible on bone scintigraphy. Positive findings obtained from radiography correlated with MR signs of fracture line or callus (p<0.001).
MR imaging is more sensitive than two-phase bone scintigraphy, and MR imaging should be used as the gold standard in the assessment of stress injuries of bone. Radiography reveals mainly the late phases of bone stress injuries, such as stress fracture and callus.
Bone mass declines and the risk of fractures increases as people age, especially as women pass through the menopause. Hip fractures, the most serious outcome of osteoporosis, are becoming more frequent than before because the world's population is ageing and because the frequency of hip fractures is increasing by 1-3% per year in most areas of the world. Rates of hip fracture vary more widely from region to region than does the prevalence of vertebral fractures. Low bone density and previous fractures are risk factors for almost all types of fracture, but each type of fracture also has its own unique risk factors. Prevention of fractures with drugs could potentially be as expensive as medical treatment of fractures. Therefore, epidemiological research should be done and used to identify individuals at high-risk of disabling fractures, thereby allowing careful allocation of expensive treatments to individuals most in need.
Diagnosis of hip fracture is normally readily made from clinical evaluation and plain radiographs. Occasionally, clinical suspicion of fracture is not confirmed on plain X-rays.
Between January 2001 and March 2002, 422 patients were admitted to our department for post-traumatic hip pain. The diagnosis of hip fracture was unequivocally made in 365 patients (86%). Fifty-seven (14%) patients had a negative or equivocal radiograph.
Limited magnetic resonance imaging (MRI) of the hip in this group of 57 patients confirmed that 8 (14%) sustained a femoral neck fracture, while 5 (9%) had an intertrochanteric fracture. In 19 patients (33%), some other pathology was found, mainly stable fractures of the femoral trochanters and pubic rami. Overall, 32 scans (56%) were positive and 25 (44%) were negative. Limited MRI detected patients with undisplaced hip fractures and identified them as candidates for surgery.
The use of MRI in this specific and 'limited' way provides orthopaedic surgeons with a rapid, accurate and cost-effective diagnostic tool in this clinical scenario. Definitive diagnosis allows the correct management plan to be implemented early. We recommend that patients, who have significant hip pain following injury but indeterminate plain radiographs, undergo a limited MRI scan as a matter of routine.
The purpose of this study was to determine the prevalence and the distribution as well as male/female differences in patients with hip or pelvic pain based on MRI results. Three hundred forty consecutive conscripts (45 women, 295 men; age range 18-29 years; mean age 20.7 years) suffering from stress-related hip, buttock or groin pain took part in the study. All 340 patients underwent MR imaging. Radiographic data were available for 215 patients. Two radiologists interpreted the images by consensus. In MRI 174 stress injuries were diagnosed in 137 patients (32 women, 105 men). The incidence of bone stress injuries in women was significantly higher than that in men ( p<0.0001). One hundred five of the injuries (60%) were related to the proximal femur, 70 (67%) to the neck, 34 (32%) to the proximal shaft, and one (1%) to the head. Sixty-nine of the 174 stress injuries (40%) concerned the pelvic bones: sacrum 28 (41%); inferior pubic ramus 34 (49%); superior pubic ramus 3 (4%); iliac bone 3 (4%); and acetabulum 1 (1%). In 31 of the 174 cases (18%) symptoms were contralateral to MR findings. Thirty-three of the 137 patients (24%) had multiple bone stress injuries, 29 had two bone stress injuries and 4 patients had three. The sensitivity of radiography was 37%, specificity 79%, accuracy 60%, positive predictive value 59% and negative predictive value 61%. The kappa value for agreement between radiography and MRI was poor (0.17, p=0.0008). Patients suffering from stress-related hip pain MRI revealed bone stress injuries in 40%; of these, 60% were located in the proximal femur and 40% in the pelvic bones. For accurate diagnosis of bone stress injuries, and to ensure appropriate treatment, the entire pelvis and both proximal femurs should be studied simultaneously by means of MRI.
Diagnosis of occult fractures about the hip
- P F Rizzo
- E S Gould
- I P Lyden
- PF Rizzo
Geriatric hip fractures: preoperative decision making
- D Feldman
- Jd Zuckerman
- Frankel