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1. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302(14):1573-1579. Review/Other-Dx 109,805 respondents, 786,717 hip fractures To examine trends in hip fracture incidence and resulting mortality over 20 years in the U.S. Medicare population. Between 1986 and 2005, the annual mean number of hip fractures was 957.3 per 100,000 (95% CI, 921.7-992.9) for women and 414.4 per 100,000 (95% CI, 401.6-427.3) for men. The age-adjusted incidence of hip fracture increased from 1986 to 1995 and then steadily declined from 1995 to 2005. In women, incidence increased 9.0%, from 964.2 per 100,000 (95% CI, 958.3-970.1) in 1986 to 1050.9 (95% CI, 1045.2-1056.7) in 1995, with a subsequent decline of 24.5% to 793.5 (95% CI, 788.7-798.3) in 2005. In men, the increase in incidence from 1986 to 1995 was 16.4%, from 392.4 (95% CI, 387.8-397.0) to 456.6 (95% CI, 452.0-461.3), and the subsequent decrease to 2005 was 19.2%, to 369.0 (95% CI, 365.1-372.8). Age- and risk-adjusted mortality in women declined by 11.9%, 14.9%, and 8.8% for 30-, 180-, and 360-day mortality, respectively. For men, age- and risk-adjusted mortality decreased by 21.8%, 25.4%, and 20.0% for 30-, 180-, and 360-day mortality, respectively. Over time, patients with hip fracture have had an increase in all comorbidities recorded except paralysis. The incidence decrease is coincident with increased use of bisphosphonates. 4
2. Stevens JA, Anne Rudd R. Declining hip fracture rates in the United States. Age Ageing. 2010;39(4):500-503. Review/Other-Dx N/A To analyze the national trends in hip fracture rates from 1990-2006 for people aged 65 years and older by both sex and 10-year age groups by using hospital discharge data. Men’s rates fell from 54.6 per 10,000 population in 1990 to 48.8 per 10,000 in 2006 (test for trend, P=0.007). However, this trend was only significant among men aged 85 and older (test for trend, P=0.005). Rates for women fell from 108.4 per 10,000 in 1990 to 91.7 per 10,000 in 2006 (test for trend, P<0.001). Examination by 10-year age groups found that the decline was significant only among women aged 75–84 (test for trend, P<0.001) and aged 85 and older (test for trend, P=0.001). For women in the oldest age group, rates peaked in 1997 and declined thereafter. 4
3. Tosteson AN, Burge RT, Marshall DA, Lindsay R. Therapies for treatment of osteoporosis in US women: cost-effectiveness and budget impact considerations. Am J Manag Care. 2008;14(9):605-615. Review/Other-Dx N/A To evaluate the cost-effectiveness of osteoporosis treatments for women at high fracture risk and estimate the population-level impact of providing bisphosphonate therapy to all eligible high-risk U.S. women. Women treated with a bisphosphonate experienced fewer fractures and more QALYs compared with no therapy or teriperatide. Total costs were lowest for the untreated cohort, followed by risedronate, alendronate, ibandronate, and teriperatide in all risk groups except women aged 75 years with previous fracture. The incremental cost-effectiveness of risedronate compared with no therapy ranged from cost saving for the base case to $66,722 per QALY for women aged 65 years with no previous fracture. Ibandronate and teriperatide were dominated in all risk groups. (A dominated treatment has a higher cost and poorer outcome.) Treating all eligible women with a bisphosphonate would cost an estimated additional $5563 million (21% total increase) and would result in 390,049 fewer fractures (35% decrease). In the highest risk group, the additional cost of therapy was offset by other healthcare cost savings. 4
4. Burge R, Dawson-Hughes B, Solomon DH, Wong JB, King A, Tosteson A. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res. 2007;22(3):465-475. Review/Other-Dx N/A To evaluate osteoporosis-related fractures and associated costs across race/ethnicity, age groups, sex, and fracture types in the United States during 2005 and projects costs and fracture incidence to the year 2025. More than 2 million incident fractures at a cost of $17 billion are predicted for 2005. Total costs including prevalent fractures are more than $19 billion. Men account for 29% of fractures and 25% of costs. Total incident fractures by skeletal site were vertebral (27%), wrist (19%), hip (14%), pelvic (7%), and other (33%). Total costs by fracture type were vertebral (6%), hip (72%), wrist (3%), pelvic (5%), and other (14%). By 2025, annual fractures and costs are projected to rise by almost 50%. The most rapid growth is estimated for people 65–74 years of age, with an increase >87%. An increase of nearly 175% is projected for Hispanic and other subpopulations. 4
5. Reider L, Hawkes W, Hebel JR, et al. The association between body mass index, weight loss and physical function in the year following a hip fracture. J Nutr Health Aging. 17(1):91-5, 2013 Jan. Review/Other-Dx 205 patients To determine whether body mass index (BMI) at the time of hospitalization or weight change in the period immediately following hospitalization predict physical function in the year after hip fracture. Lower extremity gain scale (LEGS) score and walking speed did not differ across BMI tertiles. However, grip strength differed significantly across BMI tertiles (p=0.029), with underweight women having lower grip strength than normal weight women at all time points. Women experiencing the most weight loss (>4.8%) had significantly lower LEGS scores at all time points, slower walking speed at 6 months, and weaker grip strength at 12 months post-fracture relative to women with more modest weight loss. In adjusted models, overall differences in function and functional change across all time points were not significant. However, at 12 months post fracture,women with the most weight loss had an average grip strength 7.0 kg lower than women with modest weight loss (p=0.030). 4
6. Bottle A, Aylin P. Mortality associated with delay in operation after hip fracture: observational study. BMJ. 2006;332(7547):947-951. Observational-Dx 129, 522 admissions, 151 trusts To estimate the number of deaths and readmissions associated with delay in operation after femoral fracture. There were 129,522 admissions for fractured neck of femur in 151 trusts with 18,508 deaths in hospital (14.3%). Delay in operation was associated with an increased risk of death in hospital, which was reduced but persisted after adjustment for comorbidity. For all deaths in hospital, the OR for more than one day's delay relative to one day or less was 1.27 (95% CI, 1.23 to 1.32) after adjustment for comorbidity. The proportion with more than two days' delay ranged from 1.1% to 62.4% between trusts. If death rates in patients with at most one day's delay had been repeated throughout all 151 trusts in this study, there would have been an average of 581 (478 to 683) fewer total deaths per year (9.4% of the total). There was little evidence of an association between delay and emergency readmission. 4
7. Bergeron E, Lavoie A, Moore L, et al. Is the delay to surgery for isolated hip fracture predictive of outcome in efficient systems? J Trauma. 2006;60(4):753-757. Observational-Dx 977 patients To identify the causes and outcome of delay for hip surgery in an efficient system. Overall mortality was 12.2%. Surgery was performed within 24 hours in 53% of cases and within 48 hours in 87% of cases. The presence of comorbidity partly explained longer (>48 hours) surgical delays. Multivariate analysis revealed that age greater than 65, male sex, and the presence of pulmonary and cardiac comorbid conditions or an active cancer but not surgical delay were associated with mortality and complications. However, surgical delay was associated with longer postsurgical hospital stay, independently of the presence of comorbidity or increasing age. 4
8. Bretherton CP, Parker MJ. Early surgery for patients with a fracture of the hip decreases 30-day mortality. Bone Joint J. 97-B(1):104-8, 2015 Jan. Observational-Tx 6236 patients To determine if early surgery confers an additional survival benefit at 30 days after correcting for a range of potentially confounding patient factors. In all, 6638 patients aged > 60 years were included. Worsening American Society of Anaesthesiologists grade (p < 0.001), increased age (p < 0.001) and extracapsular fracture (p < 0.019) increased the risk of 30-day mortality. Increasing mobility score (p = 0.014), mini mental test score (p < 0.001) and female gender (p = 0.014) improved survival. After adjusting for these confounders, surgery before 12 hours improved survival compared with surgery after 12 hours (p = 0.013). Beyond this the increasing delay to surgery did not significantly affect the 30-day mortality. 1
9. Daugaard CL, Jorgensen HL, Riis T, Lauritzen JB, Duus BR, van der Mark S. Is mortality after hip fracture associated with surgical delay or admission during weekends and public holidays? A retrospective study of 38,020 patients. Acta Orthop. 83(6):609-13, 2012 Dec. Observational-Tx 38,020 patients To investigate the effect of surgical delay, weekends, holidays, and time of day admission on mortality in hip fracture patients. The risk of death in hospital increased with surgical delay (odds ratio (OR) = 1.3 per 24 h of delay), American Society of Anesthesiologists (ASA) score (odd ratio (OR) (per point added) = 2.3), sex (OR for men 2.2), and age (OR (per 5 years) = 1.4). The mortality rate for patients admitted during weekends or public holidays, or at night, was similar to that found for those admitted during working days. 2
10. Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. 2009;40(7):692-697. Review/Other-Dx 52 studies involving 291,413 patients To review previous published studies on hip fractures with the aim of developing a consensus from the literature for the optimum timing for surgery for an acute hip fracture. Delaying surgery may not affect mortality but it is likely to increase morbidity, specifically the incidence of pressure sores and hospital stay. Delaying surgery will prolong distress from this type of injury, therefore, patients admitted to a hospital with a hip fracture, where there are no specific conditions that can be improved prior to surgery, should have their operation as soon as possible after admission (within 48 hours) to a hospital. 4
11. Lefaivre KA, Macadam SA, Davidson DJ, Gandhi R, Chan H, Broekhuyse HM. Length of stay, mortality, morbidity and delay to surgery in hip fractures. J Bone Joint Surg Br. 2009;91(7):922-927. Observational-Dx 607 patients To determine the effect of delay to surgery on the time to discharge, in-hospital death, the presence of major and minor medical complications and the incidence of pressure sores in patients with a fracture of the hip. Delay to surgery (P=0.0255), comorbidity (P<0.0001), age (P<0.0001) and type of fracture (P=0.0004) were all significant in the Cox proportional hazards model for increased time to discharge. Delay to surgery was not a significant predictor of in-hospital mortality. However, a delay of more than 24 hours was a significant predictor of a minor medical complication (OR 1.53, 95% CI, 1.05 to 2.22), while a delay of more than 48 hours was associated with an increased risk of a major medical complication (OR 2.21, 95% CI, 1.01 to 4.34), a minor medical complication (OR 2.27, 95% CI, 1.38 to 3.72) and of pressure sores (OR 2.29, 95% CI, 1.19 to 4.40). Patients with a fracture of the hip should have surgery early to lessen the time to acute-care hospital discharge and to minimize the risk of complications. 4
12. Novack V, Jotkowitz A, Etzion O, Porath A. Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey. Int J Qual Health Care. 2007;19(3):170-176. Observational-Dx 4,633 patients To estimate the impact of delays in surgery for hip fracture on short- and long-term outcomes. Study population comprises 4,633 patients, >65 years. The conservative approach was chosen in 818 patients (17.7%), while 1,350 patients (29.1%) waited >2 days from admission to the surgery. There was a substantial variation in median preoperative stay among the hospitals (range 0-4 days). Patients who had surgery within 2 days had lower mortality (in-hospital, 1-month and 1-year) compared to those who waited for surgery >4 days (2.9%, 4.0%, 17.4% vs 4.6%, 6.1%, 26.2%, respectively). A Cox proportional regression model of 1-year mortality in operated patients adjusted for background morbidity (Charlson index) showed that the length of operation delay has a gradual effect on increasing mortality (<2 days-reference group, 2-4 days-OR = 1.20, 5 days or longer, OR=1.50). The 818 (17.7%) nonoperated patients suffered the highest 1-year mortality, 36.2%. 4
13. Nyholm AM, Gromov K, Palm H, et al. Time to Surgery Is Associated with Thirty-Day and Ninety-Day Mortality After Proximal Femoral Fracture: A Retrospective Observational Study on Prospectively Collected Data from the Danish Fracture Database Collaborators. J Bone Joint Surg Am. 97(16):1333-9, 2015 Aug 19. Observational-Tx 3517 surgeries To evaluate the association between surgical delay and early mortality in proximal femoral fracture patients. For the 3517 surgeries included in this study, the median patient age was 82.0 years (range, fifty-one to 107 years), 2458 patients (70%) were female, and 1720 surgeries (49%) were performed because of a trochanteric fracture. Within twelve hours, 722 of the surgeries (21%) had been performed; within twenty-four hours, 2482 surgeries (71%); within thirty-six hours, 3024 surgeries (86%); within forty-eight hours, 3242 surgeries (92%); and within seventy-two hours, 3353 surgeries (95%). Unsupervised surgeons with an education level below that of an attending surgeon performed the surgery in 1807 (51%) of all cases. The thirty-day mortality was 380 (10.8%) and the ninety-day mortality was 612 (17.4%). The risk of thirty-day mortality increased with a surgical delay of more than twelve hours (odds ratio, 1.45; p = 0.02), more than twenty-four hours (odds ratio, 1.34; p = 0.02), and more than forty-eight hours (odds ratio, 1.56; p = 0.02); the risk of ninety-day mortality increased with a surgical delay of more than twenty-four hours (odds ratio, 1.23; p = 0.04). An education level of the surgeon below that of an attending surgeon increased the risk of thirty-day mortality (odds ratio, 1.28; p = 0.035) and ninety-day mortality (odds ratio, 1.26; p = 0.016). Increasing American Society of Anesthesiologists score and male sex significantly increased both thirty-day and ninety-day mortality. 2
14. Hamedan Al Maqbali MA.. History and physical examination of hip injuries in elderly adults. Orthop Nurs. 33(2):86-92; quiz 93-4, 2014 Mar-Apr. Review/Other-Dx N/A To review diagnostic tests such as radiographs and recommend appropriate management and treatment of hip fractures in elderly patients. No results stated in abstract. 4
15. Miller BJ, Callaghan JJ, Cram P, Karam M, Marsh JL, Noiseux NO. Changing trends in the treatment of femoral neck fractures: a review of the american board of orthopaedic surgery database. [Review]. J Bone Joint Surg Am. 96(17):e149, 2014 Sep 03. Review/Other-Tx 19,541 patients To investigate the trends in operative management of femoral neck fractures by orthopaedic surgeons applying for board certification. There were 19,541 femoral neck fractures that had been treated by 4450 board certification candidates. The use of total hip arthroplasty increased over time (0.7% of fractures in 1999, 7.7% in 2011, p < 0.001); use of hemiarthroplasty (67.1% in 1999, 63.1% in 2011, p = 0.020) and internal fixation (32.2% in 1999, 29.2% in 2011, p = 0.064) declined slightly. All geographic regions showed an increase in utilization of total hip arthroplasty, with substantial variation between locations. The proportion of patients younger than age sixty-five who were managed with total hip arthroplasty increased from 1.4% to 13.1% (p < 0.001). Candidates with a declared subspecialty of "adult reconstruction" showed a strong trend toward the use of total hip arthroplasty (4.3% from 1999 to 2002, 21.1% from 2009 to 2011, p < 0.001), while "trauma" subspecialty candidates demonstrated decreasing utilization of internal fixation (40.9% from 1999 to 2002, 32.9% from 2009 to 2011, p = 0.012). The percentage of candidates treating at least one femoral neck fracture decreased from 54.8% from 1999 to 2002 to 46.3% from 2009 to 2011 (p < 0.001). 4
16. Adam P.. Treatment of recent trochanteric fracture in adults. [Review]. Orthop Traumatol Surg Res. 100(1 Suppl):S75-83, 2014 Feb. Review/Other-Dx N/A To review the treatment of recent trochanteric fracture in adults. No results stated in abstract. 4
17. Stephenson JW, Davis KW. Imaging of traumatic injuries to the hip. [Review]. Semin Musculoskelet Radiol. 17(3):306-15, 2013 Jul. Review/Other-Dx N/A To review the imaging techniques of traumatic injuries to the hip. No results stated in abstract. 4
18. Naqvi SG, Iqbal S, Reynolds T, Braithwaite I, Banim R. Is a lateral view essential in management of hip fracture?. Eur J Radiol. 81(11):3394-6, 2012 Nov. Observational-Dx 25 radiographs To look at the usefulness of the lateral view radiographs in the management of fracture neck of femur. Our results showed that lateral view did not make any difference in the management in majority of the cases with excellent agreement based on kappa statistics 3
19. Harding J, Chesser TJ, Bradley M. The Bristol hip view: its role in the diagnosis and surgical planning and occult fracture diagnosis for proximal femoral fractures. ScientificWorldJournal. 2013:703783, 2013. Observational-Dx 166 patients To evaluate whether a modified radiographic view of the femoral neck improves the diagnosis of occult proximal femoral. 166 consecutive patients presenting with the clinical diagnosis of a proximal femoral fracture, of which 61 sustained a fracture. Six of these were deemed occult due to negative plain and had proven fractures on subsequent cross-sectional imaging. The Bristol hip view demonstrated five of these six fractures. It performed better than the traditional lateral hip view to identify the injury. The Bristol hip view predicted correctly the fracture type and displacement in all cases and missed only one of the occult fractures. 2
20. Cannon J, Silvestri S, Munro M. Imaging choices in occult hip fracture. J Emerg Med. 2009;37(2):144-152. Review/Other-Dx N/A To review the literature focused on hip fracture detection and discuss advantages and limitations of each major imaging modality. Plain radiographs are usually sufficient for diagnosis as they are at least 90% sensitive for hip fracture. However, in the 3%-4% of emergency department patients having hip X-ray studies who harbor an occult hip fracture, the emergency physician must choose among several methods, each with intrinsic limitations, for further evaluation. These methods include CT, scintigraphy, and MRI. 4
21. Dominguez S, Liu P, Roberts C, Mandell M, Richman PB. Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial standard radiographs--a study of emergency department patients. Acad Emerg Med. 2005;12(4):366-369. Observational-Dx 895 patients To determine the prevalence of hip and pelvic fractures in emergency department patients with hip pain and negative standard initial radiographs. 764/895 patients (85.3%) had follow-up completed (study group). Within the study group, 219 patients (29%) had evidence of fracture on initial radiographs. Of the 545 patients with negative initial radiographs, 62 patients (11.4%) underwent hip MRI during the emergency department visit. MRI identified 24 additional patients with hip fractures. Interobserver agreement for the presence of fracture on MRI was very good (kappa = 0.847). For patients with negative initial plain radiographs who did not have a hip MRI, follow-up did not identify any of these patients as having a subsequent diagnosis of fracture. Thus, 24/545 (4.4%; 95% CI, 3.0% to 6.5%) patients with negative initial plain radiographs had a hip fracture. 2
22. Feldman F, Staron RB. MRI of seemingly isolated greater trochanteric fractures. AJR. 2004;183(2):323-329. Review/Other-Dx 37 patients To show that greater trochanteric fractures commonly perceived on routine radiographs as isolated are often neither isolated nor minor and that MRI can serve as a basis for more informed treatment by revealing the actual extent of such fractures in acute posttraumatic settings. A pitfall in diagnosing seemingly isolated greater trochanteric fractures on routinely used imaging techniques lies in the fact that the injuries usually involve a large anatomic area. MRI more accurately defines the true geographic extent of greater trochanteric fractures sustained through acute trauma than do radiography and bone scintigraphy and thus could provide a more reliable basis for anticipating complications and for planning appropriate treatment. 4
23. Kirby MW, Spritzer C. Radiographic detection of hip and pelvic fractures in the emergency department. AJR. 2010;194(4):1054-1060. Observational-Dx 92 patients, 97 examinations To evaluate the detection of hip and pelvic fractures with radiography in the emergency department. 13 patients (14%) with normal radiographic findings were found to have 23 fractures at MRI (6 hip and 17 pelvic fractures). In 11 patients (12%) MRI showed no fracture after radiographic findings had suggested the presence of a fracture. In another 15 patients who had abnormal findings on radiographs, MRI depicted 12 additional pelvic fractures not identified on radiographs. In 43/59 patients (73%) without MRI evidence of a fracture, the MRI findings suggested the presence of a potential pain generator, including muscle edema and tears, trochanteric bursitis, and hamstring tendinopathy. Receiver operating characteristics analysis for the detection of hip fractures with radiography showed an area under the curve of 0.74. 3
24. Lubovsky O, Liebergall M, Mattan Y, Weil Y, Mosheiff R. Early diagnosis of occult hip fractures MRI versus CT scan. Injury. 2005;36(6):788-792. Observational-Dx 13 patients To compare CT and MRI in diagnosis of a painful hip in elderly patients after trauma. Accuracy, efficiency and benefits were also reported. In Group A where all of the 6 patients underwent CT and MRI, 4 of the CT images resulted in misdiagnosis due to inaccuracy. In Group B where all the 7 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 in patients with occult hip fracture enabling a more effective treatment, a shorter hospitalization period entailing decreased medical costs. 3
25. Sankey RA, Turner J, Lee J, Healy J, Gibbons CE. The use of MRI to detect occult fractures of the proximal femur: a study of 102 consecutive cases over a ten-year period. J Bone Joint Surg Br. 2009;91(8):1064-1068. Review/Other-Dx 102 consecutive patients To investigate the use of MRI in making an early diagnosis and formulating a management plan in patients with no visible fracture of the proximal femur on plain radiographs. There were 98 patients who fulfilled our inclusion criteria, of whom 75 were scanned within 48 hours of admission, with an overall mean time between admission and scanning of 2.4 days (0 to 10). A total of 81 patients (83%) had abnormalities detected on MRI; 23 (23%) required operative management. The use of MRI led to the early diagnosis and treatment of occult hip pathology. There is a high incidence of fractures which are not apparent on plain radiographs, and shows that MRI is useful when diagnosing other pathology such as malignancy, which may not be apparent on plain films. 4
26. Haubro M, Stougaard C, Torfing T, Overgaard S. Sensitivity and specificity of CT- and MRI-scanning in evaluation of occult fracture of the proximal femur. Injury. 46(8):1557-61, 2015 Aug. Observational-Dx 67 patients To estimate sensitivity and specificity of computed tomography (CT) and magnetic resonance imaging (MRI) examinations in patients with fractures of the proximal femur. To determine the interobserver agreement of the modalities among a senior consulting radiologist, a resident in radiology and a resident in orthopaedics surgery. 15 fractures of the proximal femur were found (7 intertrochanteric-, 3 femoral neck and 5 fractures of the greater trochanter). Two fractures were not identified by CT and four changed fracture location. Among those, three patients underwent surgery. Sensitivity of CT was 0.87; 95% CI [0.60; 0.98]. Kappa for interobserver agreement for CT were 0.46; 95% CI [0.23; 0.76] and 0.67; 95% CI [0.42; 0.90]. For MRI 0.67; 95% CI [0.43; 0.91] and 0.69; 95% CI [0.45; 0.92]. 2
27. Bogost GA, Lizerbram EK, Crues JV, 3rd. MR imaging in evaluation of suspected hip fracture: frequency of unsuspected bone and soft-tissue injury. Radiology. 1995;197(1):263-267. Review/Other-Dx 70 patients To determine the frequency of unsuspected pelvic fracture and soft-tissue injury in patients referred for MRI for possible radiographically occult hip fracture. 80% 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, MRI revealed a 27% frequency of occult pelvic fracture and a 50% frequency of bone or soft-tissue abnormality. 4
28. Collin D, Geijer M, Gothlin JH. Prevalence of exclusively and concomitant pelvic fractures at magnetic resonance imaging of suspect and occult hip fractures. EMERG. RADIOL.. 23(1):17-21, 2016 Feb. Review/Other-Dx 314 patients To retrospectively analyze the prevalence of exclusively pelvic as well as concomitant hip and pelvic fractures in patients examined with magnetic resonance imaging (MRI) after low-energy trauma in elderly. The prevalence of concomitant pelvic and femoral neck or trochanteric fractures was statistically compared using chi-squared test for categorical variables. Hip fractures were found in 161 (51 %) patients of which 29 (9 %) had concomitant pelvic fractures. There were exclusively pelvic fractures in 82 (26 %) patients of which 65 (79 %) were on the traumatized side only. In 73 patients, there were no fractures. Occult or suspected hip fractures are not infrequently associated with pelvic fractures. Exclusively pelvic fractures are not uncommon. 4
29. Galloway HR, Meikle GR, Despois M. Patterns of injury in patients with radiographic occult fracture of neck of femur as determined by magnetic resonance imaging. Australas Radiol. 2004;48(1):21-24. Review/Other-Dx 70 patient records To review retrospectively authors' experiences with MRI in patients over the age of 50 who present to the emergency department with inability to weight bear following a fall and whose initial radiographs were normal. Of these 70 patients, 23 (32.8%) had a fractured neck of femur and two patients had bilateral femoral neck fractures, giving a total of 25 fractures of the neck of femur. Of these 25 fractures, 15 (60%) were intertrochanteric fractures and 7 (28%) were subcapital fractures. There were 3 (12%) transcervical. On retrospective review of the radiographs of these fractures, 11 (44%) had findings suspicious for, but not conclusive of, fracture, 10 (40%) had no evidence of fracture, and in four (16%) plain radiographs were not available for review. Of the patients without evidence of fractured neck of femur, specific bony musculoskeletal pathology was found in 28 (40%). Of these 28 patients, 17 (61%) had insufficiency fractures of the pelvis. Of the remaining 17 (24%) patients, 11 (65%) had soft tissue abnormalities only, 7 (41%) had no fractures, no soft tissue abnormality and were otherwise normal. All patients with a fractured neck of femur or other specific bony pathology had soft tissue abnormalities for a total of 63 of 70 (90%) patients with soft tissue abnormalities. 4
30. Ohishi T, Ito T, Suzuki D, Banno T, Honda Y. Occult hip and pelvic fractures and accompanying muscle injuries around the hip. Arch Orthop Trauma Surg. 132(1):105-12, 2012 Jan. Review/Other-Dx 113 cases To investigate the incidence of occult hip and pelvic fractures and associated muscle injuries around the hip. One hundred and two cases (90.2%) had bone or soft-tissue abnormalities and 83 cases (73.5%) had fractures of the hip and/or pelvis. The frequency of hip fracture and pelvic fracture was almost the same. More than half of the patients among those with pelvic fractures sustained occult sacral fractures; therefore, it was important to determine if a sacral fracture was involved when occult hip fracture was suspected. Muscles located at the lateral aspect of the hip, such as gluteus maximus, gluteus medius, gluteus minimus and quadratus femoris, were frequently injured in cases with intertrochanteric and greater trochanter fracture, suggesting that direct impact may be associated with fractures of the trochanteric region. However, hip rotator and adductor muscles such as obturator internus, obturator externus and adductor brevis were commonly injured in cases with pelvic fracture, indicating indirect force mediated by these muscles may be associated with pelvic fracture 4
31. Ward RJ, Weissman BN, Kransdorf MJ, et al. ACR appropriateness criteria acute hip pain-suspected fracture. J. Am. Coll. Radiol.. 11(2):114-20, 2014 Feb. Review/Other-Dx N/A To provide evidence-based guidelines for acute hip pain-suspected fracture. No results stated in abstract. 4
32. Dyke JP, Lazaro LE, Hettrich CM, Hentel KD, Helfet DL, Lorich DG. Regional analysis of femoral head perfusion following displaced fractures of the femoral neck. J Magn Reson Imaging. 41(2):550-4, 2015 Feb. Observational-Dx 27 subjects To assess regional variations in the arterial and venous blood supply to the femoral head following displaced fracture of the femoral neck using dynamic contrast enhanced magnetic resonance imaging ((DCE)-MRI) quadrant analysis. Quadrant specific decreases were found in the arterial (A (0.52 versus 0.27; P = 5.7E-13), Akep (1.0/min(-1) versus 0.41/min(-1) ; P = 1.3E-9) and venous (kel (0.05/min(-1) versus -0.02/min(-1) ; P = 5.1E-5) supply to the femoral head between control and injured sides using a two-factor analysis of variance test. The fractional perfusion (initial area under the curve) in the supero/inferolateral quadrants was 49% min/54% min, in the supero/inferomedial quadrants was 43% min/46% min and for the total femoral head was 39% min on the fracture versus control sides. 3
33. Lang P, Mauz M, Schorner W, et al. Acute fracture of the femoral neck: assessment of femoral head perfusion with gadopentetate dimeglumine-enhanced MR imaging. AJR. 1993;160(2):335-341. Review/Other-Dx 13 patients To evaluate the use of MRI, before and after intravenous administration of gadopentetate dimeglumine, for assessing perfusion of the femoral head in 13 patients with acute fracture of the femoral neck. Digital subtraction angiography showed impaired blood supply to the femoral head in 5 patients. On contrast-enhanced MRIs of these patients, the femoral head did not enhance and was lower in signal intensity than were the enhancing femoral shaft and neck distal to the fracture and the enhancing femoral head on the unaffected side. In the patients with persistent perfusion, contrast-enhanced MRIs showed a uniform increase in signal intensity in the femoral shaft and neck as well as the femoral head; the femoral head on the fractured side showed contrast enhancement similar to that on the healthy side. 4
34. Thomas RW, Williams HL, Carpenter EC, Lyons K. The validity of investigating occult hip fractures using multidetector CT. Br J Radiol. 89(1060):20150250, 2016. Observational-Dx 1443 patients To establish whether multidetector Computed Tomography (MDCT) is an appropriate first-line investigation of occult femoral neck (NOF) fractures. 1443 patients were admitted during the study period. 209 (14.5%) patients had negative plain films requiring further investigation to exclude an NOF fracture, of which 199 patients had a CT. 93 patients had no fracture and 20 patients had isolated greater trochanter fractures. None of these patients progressed to develop an intracapsular femoral neck fracture at 4-month follow-up, although one patient sustained an extracapsular fracture following a high-energy fall whilst admitted. 26 femoral neck fractures were diagnosed on CT, whilst the remaining 60 patients were diagnosed with other pelvic ring fractures. 3
35. van Embden D, Scheurkogel MM, Schipper IB, Rhemrev SJ, Meylaerts SA. The value of CT compared to radiographs in the classification and treatment plan of trochanteric fractures. Arch Orthop Trauma Surg. 136(8):1091-7, 2016 Aug. Observational-Dx 30 patients To evaluate and compare the reliability of the Arbeitsgemeinschaft für Osteosynthesefragen (AO) main group classification (31-A1, A2, A3) for trochanteric fractures, assessed on both radiographs and computed tomography (CT). The inter-observer agreement was kappa0.70 (SE 0.03) for radiographic assessment of the main groups of the AO classification and kappa0.68 (SE 0.03) for CT assessment. The agreement on choice of implant was kappa0.63 (SE 0.05) if the choice was made with radiographs and kappa0.69 (SE 0.05) with CTs. Six out of the 13 fractures were classified differently after assessment of the CT. Most corrections in choice of implant occurred for the assessment of A3 fractures. 3
36. Safran O, Goldman V, Applbaum Y, et al. Posttraumatic painful hip: sonography as a screening test for occult hip fractures. J Ultrasound Med. 2009;28(11):1447-1452. Observational-Dx 30 patients To evaluate sonography as a screening tool for occult hip fractures in posttraumatic painful hips in elderly patients. 10 hip fractures were diagnosed by MRI. Sonography showed trauma-related changes in all of those patients and in 7 additional patients, 3 of whom had pubic fractures. Sonography correctly identified 13 patients without hip fractures. The sensitivity of sonography was found to be 100%, whereas the specificity for hip fractures was 65%. 2
37. Quinn SF, McCarthy JL. Prospective evaluation of patients with suspected hip fracture and indeterminate radiographs: use of T1-weighted MR images. Radiology. 1993;187(2):469-471. Observational-Dx 20 patients To assess the diagnostic efficacy of T1-weighted MRI when findings on radiographs of the hip are indeterminate. When MRI and clinical outcome were used as the standard of reference, the prospective accuracy of MRI in diagnosis of the presence or absence of hip fracture was 100%. All MRI studies were diagnostic. Of the 13 patients with fracture (8 with trochanteric and 5 with subcapital fracture), 10 patients (77%) underwent surgery and 3 patients (23%) received conservative treatment. T1-weighted MRI can enable diagnosis or exclusion of hip fracture whenever radiographs are indeterminate. 3
38. Pandey R, McNally E, Ali A, Bulstrode C. The role of MRI in the diagnosis of occult hip fractures. Injury. 1998;29(1):61-63. Review/Other-Dx 33 patients To assess the role of MRI in the diagnosis of occult hip fractures. MRI scans were done on 33 patients who had post-traumatic painful hips but negative radiographs. 40% of the patients had sustained a fractured neck of femur, 15% had sustained an intertrochanteric fracture and 11% had sustained other fractures around the hip; in one patient a tumor was demonstrated. No fracture was seen in 30% of the patients scanned. MRI is well tolerated by elderly patients in pain, does not involve ionizing radiation and provides early and accurate diagnosis in patients with X-ray negative post-traumatic hip pain. 4
39. Cabarrus MC, Ambekar A, Lu Y, Link TM. MRI and CT of insufficiency fractures of the pelvis and the proximal femur. AJR. 2008;191(4):995-1001. Observational-Dx 145 patients To compare the sensitivity of CT and MRI in detecting insufficiency fractures; to analyze the typical location, morphology, and combinations thereof in these fractures; to analyze imaging morphology; and to analyze associated clinical findings. In the subgroup undergoing both imaging techniques, MRI detected 128/129 (99%) fractures in 63/64 (98%) subjects, whereas CT detected only 89/129 (69%) fractures in 34/64 (53%) subjects. In particular, fractures at the femoral head and acetabulum were better detected with MRI. In the complete population, two or more fractures were found in 70.3% (102/145) of patients and 89.2% (33/37) of patients with pubic insufficiency fractures had concomitant fractures at other locations. In 63/145 (43.4%) patients, a previous malignancy was found; in only 93/145 (64.1%) patients, the leading symptom responsible for the MRI examination was pain. 3
40. Schultz E, Miller TT, Boruchov SD, Schmell EB, Toledano B. Incomplete intertrochanteric fractures: imaging features and clinical management. Radiology. 1999;211(1):237-240. Review/Other-Dx 31 patients To present the imaging findings and treatment options for incomplete intertrochanteric fractures. The correlation between radiographic and MR findings was poor. Incomplete intertrochanteric fracture was the prospective radiographic diagnosis in only one case. Fracture in 18 patients was treated surgically and in 13 was managed conservatively. In both groups, the average age of the patients and length of the fractures and the percentage of separate fractures involving the greater trochanter and crossing the midline of the femur in the axial plane were the same. Fractures crossed the midline in the coronal plane in 50% of the surgical group but in only 23% of the nonsurgical group. Average time from injury to ambulation was 2 days less in the surgical group, but no difference in functional status was found subjectively between the two groups at clinical follow-up. 4
41. Alam A, Willett K, Ostlere S. The MRI diagnosis and management of incomplete intertrochanteric fractures of the femur. J Bone Joint Surg Br. 2005;87(9):1253-1255. Observational-Dx 68 patients To establish whether incomplete intertrochanteric fractures can be successfully managed conservatively. A hip fracture was suspected in 18 patients despite normal plain radiographs; these patients were subsequently found to have a fracture of the femoral neck (10 intracapsular, 8 intertrochanteric). The 8 patients with an intertrochanteric fracture (5 men, 3 women) did not have shortening of the lower limb, or an external rotation deformity on examination. 3 patients, with a mean age of 61 years (standard deviation 5.6) were managed with a dynamic hip screw and 5 patients, with a mean age of 73.4 (standard deviation 17.2) were considered to be a high anesthetic risk and were, therefore, treated conservatively. The mean length of hospital stay in the conservatively-treated group was 16 days (standard deviation 4.2) but 15 days (standard deviation 3.0) for those treated with surgery; this was not statistically significant (P>0.5). All patients were mobilized with walking support on discharge. One patient developed a wound haematoma, which was the only known surgical complication in this group. No patient who had been treated conservatively was readmitted for a complete fracture although 5 were readmitted for unrelated reasons (2 operative, 3 nonoperative). The mean time of readmission after fracture was 3.2 years (2 to 5) although all 5 patients had been mobilizing independently, with walking support, by the time of their readmission. 4
42. Khoury NJ, Birjawi GA, Chaaya M, Hourani MH. Use of limited MR protocol (coronal STIR) in the evaluation of patients with hip pain. Skeletal Radiol. 2003;32(10):567-574. Observational-Dx 93 MR studies To assess the role of a limited magnetic resonance (MR) protocol (coronal short tau inversion-recovery (STIR)) as the initial part of the MR examination in patients with hip pain. For both readers, all normal MR examinations on the coronal STIR limited protocol were normal on the full protocol, with an interobserver reliability of 0.96. The STIR protocol was able to detect the presence or absence of an abnormality in 100% of cases (sensitivity). The STIR-only protocol provided a specific diagnosis in only 65% of cases (specificity). 3
43. Khurana B, Okanobo H, Ossiani M, Ledbetter S, Al Dulaimy K, Sodickson A. Abbreviated MRI for patients presenting to the emergency department with hip pain. AJR Am J Roentgenol. 2012;198(6):W581-588. Observational-Dx 385 patients To assess the diagnostic performance of two abbreviated hip Magnetic Resonance Imaging (MRI) protocols--coronal Short tau inversion recovery (STIR) images only and coronal STIR with coronal T1-weighted images--as compared with a full hip MRI protocol in patients presenting to the emergency department (ED) with hip pain and negative radiographic findings. MRI detected findings suspicious for fracture in 42% (162/385) of patients, for avascular necrosis (AVN) in 9% (33/385), and for muscle injury in 35% (134/385). The sensitivity and specificity of STIR alone in raising concern for fracture was 99% (220/223) for both readers, with small incremental benefits of adding coronal T1-weighted images. For AVN, specificity was 100% (28/28) with STIR alone, but the addition of coronal T1-weighted images provided substantial benefit by increasing sensitivity from 85% (28/33) to 97% (32/33). For muscle injury, sensitivity and specificity exceeded 95% (128/134) for both abbreviated examinations. 2
44. Hirata T, Konishiike T, Kawai A, Sato T, Inoue H. Dynamic magnetic resonance imaging of femoral head perfusion in femoral neck fracture. Clin Orthop Relat Res. 2001;(393):294-301. Observational-Dx 36 femoral neck fractures Prospective follow-up study of femoral neck fractures according to the assessment of femoral head perfusion using dynamic MRI. Patients were divided into three groups based on the dynamic MRI findings (dynamic curve pattern and relative enhancement ratio) that were conducted within 48 hours of the injury. Traction was used to achieve anatomic reduction and to prevent additional damage to vascularity until minimally invasive internal fixation could be done. The fractures of all 17 patients whose femoral head perfusion was normal (Type A; n=11) or was impaired but not totally absent (Type B; n=6) healed without complications. Among the 19 patients whose femoral head perfusion was absent (Type C), 15 had complications (osteonecrosis, n=10; nonunion, n=5). Assuming that fractures with a Type A or Type B curve pattern would unite successfully and that those with a Type C curve pattern would not, the sensitivity, specificity, and accuracy of the predictions of successful osteosynthesis of the femoral neck fractures using this method were 81%, 100%, and 89%, respectively. 3
45. Kaushik A, Sankaran B, Varghese M. Prognostic value of dynamic MRI in assessing post-traumatic femoral head vascularity. Skeletal Radiol. 2009;38(6):565-569. Observational-Dx 30 patients with 31 hips To evaluate the role of dynamic MRI in predicting femoral head vascularity and thereby avascular necrosis after intracapsular femoral neck fractures. Fractures were divided into 3 types (Type A, B, or C) based on the femoral head vascularity shown by dynamic curve patterns on MRI evaluation. Type A was preserved vascularity, Type B was some decrease in vascularity but still viable while Type C was significantly reduced vascularity. Type A curves correlate well with vascular status and Type C curves correlate well with poor vascularity of the femoral heads. No avascular necrosis was seen in any of Type A (13/31) or Type B (eight out of 31). 5 cases showed avascular necrosis and all of them were of Type C dynamic curves. Dynamic MRI is a reliable tool to evaluate vascularity of femoral heads and thus reduces the uncertainty of outcome of treatment of intracapsular femoral neck fractures. Dynamic MRI can be a useful tool to formulate a treatment algorithm in management of intracapsular femoral neck fracture. 3
46. Heikal S, Riou P, Jones L. The use of computed tomography in identifying radiologically occult hip fractures in the elderly. Ann R Coll Surg Engl. 96(3):234-7, 2014 Apr. Observational-Dx 65 patients To identify the number of patients whose management was changed as a result of multidetector Computed tomography (MDCT). Of the 65 included patients, fractures (pelvic and hip) were identified in 38 patients on CT. Fractured neck of femur (NOF) were found in 13 patients. Acetabular fractures were found in nine patients, five of whom required further orthopaedic management. One patient went on to have MRI to confirm the diagnosis of an impacted NOF fracture, suspected both on x-ray and CT. Further review was undertaken of the medical notes of discharged patients to identify any who reattended or required further imaging. No such cases were found. 3
47. Dunker D, Collin D, Gothlin JH, Geijer M. High clinical utility of computed tomography compared to radiography in elderly patients with occult hip fracture after low-energy trauma. Emerg Radiol. 2012;19(2):135-139. Observational-Dx 193 hip CT examinations To evaluate the clinical utility of CT compared to radiography in evaluating suspect or missed hip fractures in elderly after low-energy trauma. 84 examinations revealed no fracture. Follow-up was uneventful but for 2 patients who had been operated. 39/41 cervical hip fractures were surgically or otherwise confirmed, 2 cases were not operated due to week-old trauma and moderate symptoms. 29/68 trochanteric fractures or avulsions were confirmed surgically. CT has a high clinical utility as it can detect nearly all clinically suspect but radiographically negative cervical hip fractures as well as most trochanteric fractures and avulsions. A negative CT is near-perfect in ruling out a hip fracture requiring surgery. 3
48. Hakkarinen DK, Banh KV, Hendey GW. Magnetic resonance imaging identifies occult hip fractures missed by 64-slice computed tomography. J Emerg Med. 43(2):303-7, 2012 Aug. Observational-Dx 235 hip fractures To determine the incidence of occult hip fractures missed by 64-slice computed tomography (CT) but detected by magnetic resonance imaging (MRI). Of 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. 3
49. Reddy T, McLaughlin PD, Mallinson PI, et al. Detection of occult, undisplaced hip fractures with a dual-energy CT algorithm targeted to detection of bone marrow edema. EMERG. RADIOL.. 22(1):25-9, 2015 Feb. Observational-Dx 25 patients To describe our initial clinical experience with dual-energy computed tomography (DECT) virtual non-calcium (VNC) images for the detection of bone marrow (BM) edema in patients with suspected hip fracture following trauma. Twenty-one patients were found to have DECT-VNC signs of bone marrow edema. Eighteen of these 21 patients were true positive and three were false positive. A concordant fracture was clearly seen on bone reconstruction images in 15 of the 18 true positive cases. In three cases, DECT-VNC was positive for bone marrow edema where bone reconstruction CT images were negative. Four patients demonstrated no DECT-VNC signs of bone marrow edema: two cases were true negative, two cases were false negative. When compared with the gold standard of hip fracture determined at retrospective follow-up, the sensitivity of DECT-VNC images of the hip was 90 %, specificity was 40 %, positive predictive value was 86 %, and negative predictive value was 50 %. 2
50. Rizzo PF, Gould ES, Lyden JP, Asnis SE. Diagnosis of occult fractures about the hip. Magnetic resonance imaging compared with bone-scanning. J Bone Joint Surg Am. 1993;75(3):395-401. Observational-Dx 62 patients To compare MRI with bone-scanning for the diagnosis of occult fractures about the hip. 36 patients who had evidence of a fracture on the MRI study also had a positive bone scan initially. 23 patients who had a negative finding on the MRI study had a corresponding negative bone scan. Two additional patients had evidence of avascular necrosis of the femoral head on both the MRI and the bone scan, and they were managed non-operatively. One patient had a positive MRI and a negative bone scan 24 hours after admission. A repeat bone scan, which was made 6 days later, was positive for a fracture of the femoral neck and the patient was managed with internal fixation. MRI was as accurate as bone-scanning in the assessment of occult fractures of the hip and 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. 3
51. Rubin SJ, Marquardt JD, Gottlieb RH, Meyers SP, Totterman SM, O'Mara RE. Magnetic resonance imaging: a cost-effective alternative to bone scintigraphy in the evaluation of patients with suspected hip fractures. Skeletal Radiol. 1998;27(4):199-204. Review/Other-Dx 40 patients To evaluate the cost-effectiveness of MRI compared with radionuclide bone scan in the evaluation of patients with clinically suspected hip fractures. 21 patients had bone scans (6 with fractures), and 19 had MRI (4 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). 20 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. 4
52. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4