Diagnosis Of Occult Hip Fractures Research Articles

Cost-Effective Analysis of Dual-Energy Computed Tomography for the Diagnosis of Occult Hip Fractures Among Older Adults

ObjectiveEarly 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. MethodsA 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. ResultsThe 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. ConclusionDECT 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.

Use of Multislice CT for Investigation of Occult Geriatric Hip Fractures and Impact on Timing of Surgery.

Introduction:The National Institute of Health and Clinical Excellence guidelines in the United Kingdom recommend magnetic resonance imaging (MRI) as the first-line investigation for radiographically occult hip fractures, if available within 24 hours. In our department, however, multislice computerized tomography (MSCT) is instead used as a first-line investigation due to significant delays associated with obtaining MRI. Our aim was to determine the validity and practicality of MSCT for diagnosis of occult hip fractures and its impact on timing of surgery.Materials and Methods:We retrospectively analyzed medical records and imaging for consecutive patients who underwent MSCT to investigate occult hip fractures between January 2014 and October 2016. We reviewed subsequent imaging and reattendances for patients with negative MSCT to exclude initially missed fractures.Results:Two hundred six patients underwent MSCT to investigate occult hip fracture during the study period. Hip fractures were identified in 59 patients, comprising 35 (59.3%) subcapital, 12 (20.0%) intertrochanteric, 8 (13.6%) transcervical, and 4 (6.8%) basicervical fractures. One missed hip fracture was identified: a patient with a negative MSCT was further investigated with MRI that demonstrated acute subcapital hip fracture. Multislice computerized tomography was obtained within 24 hours of initial radiograph in 145 (70.4%) patients. A total of 44.5% of occult hip fractures had surgery within the nationally recommended 36 hours of admission (hospital average for all hip fractures was 76.4% over the same period).Discussion and Conclusions:Multislice computerized tomography is a pragmatic approach to investigate the majority of occult hip fractures in a timely manner and minimize associated delay to surgery. However it cannot completely exclude the diagnosis, especially in abnormal anatomy. The lack of a true gold standard comparison (ie, MRI) means a true sensitivity and specificity cannot be calculated, although can be cautiously estimated by lack of subsequent reattendance or investigation. Further prospective randomized CT versus MRI trials are required.

Diagnostic Imaging Strategies for Occult Hip Fractures: A Decision and Cost-Effectiveness Analysis.

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 tomography (CT), performing only magnetic resonance imaging (MRI), performing CT and if negative performing MRI (MRI-selective strategy) or discharging the patient without advanced imaging. 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. 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 $1,228, 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. 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.

Analysis of Initial Injury Radiographs of Occult Femoral Neck Fractures in Elderly Patients: A Pilot Study

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

Magnetic Resonance Imaging Identifies Occult Hip Fractures Missed by 64-slice Computed Tomography

BackgroundCiting the enhanced resolution of 64-slice computed tomography (CT), some clinicians now use CT instead of magnetic resonance imaging (MRI) to detect occult hip fracture. ObjectiveOur objective was to determine the incidence of occult hip fractures missed by 64-slice CT but detected by MRI. MethodsWe reviewed the medical records and radiology reports of patients over age 60 years with a hip fracture (acetabular, intertrochanteric, trochanteric, femoral neck, and femoral head) during a 3-year period, January 1, 2007 through December 31, 2009. We also reviewed all hip CT and MRI scans ordered during that period. Occult fractures were those visualized on CT or MRI but with negative plain films. We compared CT and MRI findings, and calculated percentages and 95% confidence intervals (CIs). ResultsOf 235 hip fractures, 211 were visible on initial plain films (90%, 95% CI 85–93%) and 24 (10%, 95% CI 6–15%) were occult. Eighteen occult fractures (7.6%, 95% CI 4.6–11.8%) were identified by CT (MRI not done), one (0.4%, 95% CI 0–2%) by MRI (CT not done), one (0.4%, 95% CI 0–2%) by both CT and MRI, and 4 patients (1.7%, 95% CI 0.5–4.3%) had a positive MRI but negative CT scan. ConclusionAlthough 64-slice CT detected the majority of occult fractures, it missed four (2%) significant fractures detected by MRI. CT scan is helpful in the diagnosis of occult hip fracture, but one should not completely exclude the diagnosis based on a negative 64-slice CT scan in a patient with persistent, localized hip pain who cannot bear weight.

Bone bruise, lipohemarthrosis, and joint effusion in CT of non-displaced hip fracture

A suspected occult hip fracture after normal radiography is not uncommon in an elderly person after a fall. Despite a lack of robust validation in the literature, computed tomography (CT) is often used as secondary imaging. To assess the frequency and clinical utility of non-cortical skeletal and soft tissue lesions as ancillary fracture signs in CT diagnosis of occult hip fractures. All fracture signs (cortical and trabecular fractures, bone bruise, joint effusion, and lipohemarthrosis) were recorded in 231 hip low-energy trauma cases with CT performed after normal or equivocal radiography in two trauma centers. There were no fracture signs in 110 patients. Twelve of these had a joint effusion. In 121 patients with 46 cervical hip fractures and 75 trochanteric fractures one or more fracture signs were present. Cortical fractures were found in 115 patients. Bone bruise was found in 119 patients, joint effusion in 35, and lipohemarthrosis in 20 patients. Ancillary signs such as bone bruise and lipohemarthrosis can strengthen and sometimes indicate the diagnosis in CT of occult hip fractures. Joint effusion is a non-specific sign.

The role of CT and MRI in the diagnosis of occult hip fractures

The role of CT and MRI in the diagnosis of occult hip fractures

Early diagnosis of occult hip fractures: MRI versus CT scan

We compared Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI) in diagnosis of a painful hip in elderly patients after trauma. We report on accuracy, efficiency and benefits. We assessed 13 patients, average age 73 years, after fall with plain X-rays showing no evidence of fracture. There were two groups: Group A (six patients) underwent CT and MRI; Group B underwent MRI only. In Group A where all of the six patients underwent CT and MRI, four of the CT images resulted in misdiagnosis due to inaccuracy. In Group B where all the seven patients underwent only MRI, all the results were accurate and enabled a precise and fast diagnosis. MRI was found to be a more accurate modality than CT scan for obtaining early diagnosis of occult hip fractures. These results point out the advantage of immediate MRI imaging in patients with occult hip fracture enabling a more effective treatment, a shorter hospitalisation period entailing decreased medical costs.

Use of percussion as a screening tool in the diagnosis of occult hip fractures

Use of percussion as a screening tool in the diagnosis of occult hip fractures

Limited magnetic resonance imaging in the diagnosis of occult hip fractures

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.

The role of MRI in the diagnosis of occult hip fractures

Undisplaced fractures of the hip can occasionally be difficult to diagnose on radiographs. We performed MRI scans on 33 patients who had post-traumatic painful hips but negative radiographs. Forty per cent of the patients had sustained a fractured neck of femur, 15 per cent had sustained an intertrochanteric fracture and 11 per cent had sustained other fractures around the hip; in one patient a tumour was demonstrated. No fracture was seen in 30 per cent of the patients scanned. MRI is well tolerated by elderly patients in pain, does not involve ionising radiation and provides early and accurate diagnosis in patients with X-ray negative post-traumatic hip pain.

Costs associated with total hip arthroplasty and the diagnosis of occult hip fractures.

Costs associated with total hip arthroplasty and the diagnosis of occult hip fractures.