Probability of Occult Ankle Fracture Based on Radiograph-Measured Swelling.

INTRODUCTION: Pediatric ankle injuries are a common presentation in the emergency department (ED). A quarter of pediatric ankle fractures show no radiographic evidence of a fracture. Physicians often correlate non-weight bearing and tenderness with an occult fracture. We present this study to predict the probability of an occult fracture using radiographic soft-tissue swelling on initial ED radiographs. METHODS: This is a retrospective study at a Level 1 pediatric trauma center from 2021 to 22. Soft-tissue swelling between the lateral malleolus and skin was measured on radiographs, and weight-bearing status was documented. Statistical analysis was conducted using Stata software. DISCUSSION: The study period involved 32 patients with an occult fracture, with 8 (25%) diagnosed with a fracture on follow-up radiographs. The probability of an occult fracture was calculated as a function of the ankle swelling in millimeters (mm) using a computer-generated predictive model. False-negative and false-positive rates were plotted as a function of the degree of ankle swelling. CONCLUSION: Magnitude of ankle soft-tissue swelling as measured on initial ED radiographs is predictive of an occult fracture. Although weight-bearing status was not a sign of occult fracture, it improves the predictive accuracy of soft-tissue swelling.

The rate of nonunion in the MRI-detected occult scaphoid fracture.

Aims: There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures. Methods: This multicentre cohort study at eight centres in the UK included all patients with an acute scaphoid fracture diagnosed on MRI having presented acutely following wrist trauma with normal radiographs. Data were gathered retrospectively for a minimum of 12 months at each centre. The primary outcome measures were the rate of acute surgery, delayed union, and nonunion. Results: A total of 1,989 patients underwent acute MRI for a suspected scaphoid fracture during the study period, of which 256 patients (12.9%) were diagnosed with a previously occult scaphoid fracture. Of the patients with scaphoid fractures, six underwent early surgical fixation (2.3%) and there was a total of 16 cases of delayed or nonunion (6.3%) in the remaining 250 patients treated with cast immobilization. Of the nine nonunions (3.5%), seven underwent surgery (2.7%), one opted for non-surgical treatment, and one failed to attend follow-up. Of the seven delayed unions (2.7%), one (0.4%) was treated with surgery at two months, one (0.4%) did not attend further follow-up, and the remaining five fractures (1.9%) healed after further cast immobilization. All fractures treated with surgery had united at follow-up. There was one complication of surgery (prominent screw requiring removal). Conclusion: MRI-detected scaphoid fractures are not universally benign, with delayed or nonunion of scaphoid fractures diagnosed only after MRI seen in over 6% despite appropriate initial immobilization, with most of these patients with nonunion requiring surgery to achieve union. This study adds weight to the evidence base supporting the use of early MRI for these patients.

The utility of standing knee radiographs for detection of lipohemarthrosis: comparison with supine horizontal beam radiographs.

OBJECTIVES: Lipohemarthrosis is a key finding in acute trauma patients and indicates an intra-articular fracture. The horizontal beam lateral radiography with supine position is known to be the best technique to demonstrate knee lipohemarthrosis. Our main purpose was to compare the sensitivity of supine and standing lateral knee radiographs to detect lipohemarthrosis. METHODS: In our retrospective study, consecutive patients with lipohemarthrosis on computed tomography of the knee between October 2019 and September 2021 were included. Fractured bone, the presence of lipohemarthrosis, and image quality in both standing and supine anteroposterior and lateral knee radiographs were evaluated. Interobserver reliability of the three observers was calculated. Fisher exact chi-square and z-proportion tests were used to compare lateral and anteroposterior knee radiographs. Krippendorff's Alpha and Kappa coefficients were used for inter-observer agreement. RESULTS: A total of 61 patients (38 men [62.3%], 23 women [37.7%]; mean age, 43 years ± 17 [standard deviation]) were included. The most common type of fracture was isolated tibial fractures (n = 32; 52.5%). The sensitivity of showing lipohemarthrosis of standing lateral knee radiographs (95.5%) was higher than supine lateral radiographs (38.5%) (p < 0.001). While non-optimal image quality did not affect lipohemarthrosis detection on lateral radiographs (p > 0.99), it caused a significant decrease in the diagnosis of lipohemarthrosis on anteroposterior radiographs (p = 0.036). We found a good-excellent interobserver agreement in lipohemarthrosis detection. CONCLUSIONS: Standing lateral radiographs have higher sensitivity than supine lateral radiographs in detecting lipohemarthrosis and are beneficial for detecting lipohemarthrosis which indicates the presence of occult-evident intraarticular fracture in patients with knee trauma. CLINICAL RELEVANCE STATEMENT: Standing lateral knee radiographs offer a useful method for reducing the misdiagnosis of the occult intra-articular fractures by showing the fat-fluid leveling more clearly. Its advantages may be more prominent when the advanced imaging modalities are limited. KEY POINTS: • Fat-fluid level (lipohemarthrosis) is an important radiographic sign to assess patients with acute trauma. It almost always indicates an intra-articular fracture. • Our retrospective study results support that lipohemarthrosis sign could be observed more frequently in standing lateral knee radiographs than in supine lateral radiographs. • Knee trauma patients, when available, should be evaluated with standing lateral radiographs for the diagnosis of lipohemarthrosis.

Can a Deep Learning Algorithm Improve Detection of Occult Scaphoid Fractures in Plain Radiographs? A Clinical Validation Study.

BACKGROUND: Occult scaphoid fractures on initial radiographs of an injury are a diagnostic challenge to physicians. Although artificial intelligence models based on the principles of deep convolutional neural networks (CNN) offer a potential method of detection, it is unknown how such models perform in the clinical setting. QUESTIONS/PURPOSES: (1) Does CNN-assisted image interpretation improve interobserver agreement for scaphoid fractures? (2) What is the sensitivity and specificity of image interpretation performed with and without CNN assistance (as stratified by type: normal scaphoid, occult fracture, and apparent fracture)? (3) Does CNN assistance improve time to diagnosis and physician confidence level? METHODS: This survey-based experiment presented 15 scaphoid radiographs (five normal, five apparent fractures, and five occult fractures) with and without CNN assistance to physicians in a variety of practice settings across the United States and Taiwan. Occult fractures were identified by follow-up CT scans or MRI. Participants met the following criteria: Postgraduate Year 3 or above resident physician in plastic surgery, orthopaedic surgery, or emergency medicine; hand fellows; and attending physicians. Among the 176 invited participants, 120 completed the survey and met the inclusion criteria. Of the participants, 31% (37 of 120) were fellowship-trained hand surgeons, 43% (52 of 120) were plastic surgeons, and 69% (83 of 120) were attending physicians. Most participants (73% [88 of 120]) worked in academic centers, whereas the remainder worked in large, urban private practice hospitals. Recruitment occurred between February 2022 and March 2022. Radiographs with CNN assistance were accompanied by predictions of fracture presence and gradient-weighted class activation mapping of the predicted fracture site. Sensitivity and specificity of the CNN-assisted physician diagnoses were calculated to assess diagnostic performance. We calculated interobserver agreement with the Gwet agreement coefficient (AC1). Physician diagnostic confidence was estimated using a self-assessment Likert scale, and the time to arrive at a diagnosis for each case was measured. RESULTS: Interobserver agreement among physicians for occult scaphoid radiographs was higher with CNN assistance than without (AC1 0.42 [95% CI 0.17 to 0.68] versus 0.06 [95% CI 0.00 to 0.17], respectively). No clinically relevant differences were observed in time to arrive at a diagnosis (18 ± 12 seconds versus 30 ± 27 seconds, mean difference 12 seconds [95% CI 6 to 17]; p < 0.001) or diagnostic confidence levels (7.2 ± 1.7 seconds versus 6.2 ± 1.6 seconds; mean difference 1 second [95% CI 0.5 to 1.3]; p < 0.001) for occult fractures. CONCLUSION: CNN assistance improves physician diagnostic sensitivity and specificity as well as interobserver agreement for the diagnosis of occult scaphoid fractures. The differences observed in diagnostic speed and confidence is likely not clinically relevant. Despite these improvements in clinical diagnoses of scaphoid fractures with the CNN, it is unknown whether development and implementation of such models is cost effective. LEVEL OF EVIDENCE: Level II, diagnostic study.

Children With Elbow Injuries and Sonographic Elevated Posterior Fat Pad but No Identifiable Posterior Fat Pad on Lateral Radiographs: A Case Series.

Point of Care Ultrasound (POCUS) is used to evaluate the injured pediatric elbow. Standard of care, however, remains radiography. POCUS performed in the setting of normal radiographs have been obtained may demonstrate radiologic occult lipohemarthrosis indicative of occult fracture. We reviewed our pediatric emergency department (PED) POCUS archive for lipohemarthrosis, and then isolated those cases with normal elbow radiography. Radiography was deemed to be normal per the interpretation of the treating PED physician, and was reviewed for this series by an experienced ABR board certified pediatric radiologist. Fracture on POCUS was defined as fracture line or lipohemarthrosis in a posterior sagittal or transverse view of the distal humerus. Fracture was confirmed by signs of cortical healing on follow-up radiography, or clinical course consistent with fracture as documented by an orthopedist. We identified four children with elbow fractures who had no fracture line or elevated posterior fat pad on radiography but demonstrated lipohemarthrosis on POCUS. POCUS may elicit evidence of fracture even after normal radiography, and POCUS findings suggesting occult fracture may allow for more effective guidance on discharge.

Prospective comparison of magnetic resonance imaging and computed tomography in diagnosing occult scaphoid fractures.

BACKGROUND: Suspected scaphoid fracture (SF) after a fall on an outstretched hand is a common presentation in the emergency department. Magnetic resonance imaging (MRI) or computed tomography (CT) has been suggested to assist in the diagnosis or exclusion of SF. PURPOSE: To compare MRI and CT at diagnosing occult SFs. MATERIAL AND METHODS: We routinely perform CT scans in patients with clinically suspected occult SF, after 7-10 days of injury following two negative radiographs. All eligible patients with a clinically suspected SF, but negative radiographs and a negative CT, underwent an MRI scan to assess further for evidence of occult fracture. RESULTS: A total of 100 patients were included in our study. MRI showed fractures in 16% of the time (in 15 patients) when plain radiographs and CT did not. Of these fractures, 8% were SFs. In addition to fractures, 10% had bone bruising. A total of 25% of patients with fractures and bone bruising were referred to the hand surgery team for further follow-up. CONCLUSION: The study demonstrated that MRI would identify a radiographically occult SF more often than CT. This supports NICE guidelines which recommend MRI as the best early diagnostic tool for occult SFs.

[Comparison of multislice spiral CT and MRI in diagnosis of occult fracture of knee joint with meniscus and ligament injury].

OBJECTIVE: To investigate the diagnostic value of multislice spiral CT (MSCT) and MRI in occult fracture of knee joint with meniscus and ligament injury. METHODS: From January 2020 to March 2021, 63 patients with knee occult fracture with meniscus and ligament injury, including 41 males and 22 females, aged from 21 to 67 years old, with an average of (44.35±8.77) years old, the course of disease ranged from 1 to 6 days, with an average of (4.64±1.75) days, the body mass index (BMI) was (19.85±2.78) kg/m2. MSCT and MRI data of 63 patients were collected and statistically analyzed to evaluage their diagnist value. RESULTS: The detection of MRI for occult knee fravtures with meniscus and ligament injury, joint cavity effusion, bone marrow edema, and articular surface injury were 100.00% (63/63), 95.24% (60/63), 42.86% (27/63) and 36.51% (23/63), respectively. The detection rates of MSCT were 49.21% (31/63), 41.27% (26/63), 0.00% (0/63) and 1.59% (1/63), respectively, significantly lwver than that of MRI (P<0.05). The diagnostic sensitivity, specificity and accuracy of MRI were significantly higher than those of MSCT(P<0.05). CONCLUSION: The sensitivity, specificity and accuracy of magnetic resonance imaging in the diagnosis of occult fracture of knee joint with meniscus and ligament injury are significantly better than that of MSCT. MRI has higher accuracy in the diagnosis of peripheral tissue diseases such as joint cavity, articular surface and bone marrow, and can reduce the risk of clinical misdiagnosis.

Diagnostic Value Comparison between Multislice Spiral Computerized Tomography and Magnetic Resonance Imaging under Artificial Intelligence Algorithm in Diagnosing Occult Fractures of the Knee Joint.

The aim of this study was to explore the application value of multislice spiral computerized tomography (MSCT) and magnetic resonance imaging (MRI) under intelligent algorithm in the diagnosis of occult fractures of the knee joint (OFKJ). 47 patients with negative X-ray examination and suspected fracture were included for this research. According to the examination methods, the patients were divided into the MSCT group and MRI group. The diagnostic results of the two methods were compared, and then compared with the traditional algorithm to explore their superiorities. The results demonstrated that the algorithm applied in this study had a clearer segmentation than traditional algorithms, and it run significantly faster than other algorithms. The results of MSCT, MRI, and pathological examination were all different, but which was of no statistical significance, P > 0.05. The specificity, accuracy, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of MSCT were 83%, 96%, 94%, and 98%, respectively; and its coincidence rate, missed diagnosis rate, and misdiagnosis rate were 98.20%, 1.60%, and 0.20%, respectively. Compared with MRI, the differences were significant statistically, P < 0.05. The segmentation effect of MSCT was closer to the standard segmentation, with the higher efficiency. MSCT under the intelligent algorithm produced the better diagnostic performance and the higher detection rate than MRI in diagnosing OFKJ. It could be used for clinical auxiliary diagnosis and evaluation of OFKJ, deserving an application value.

Clinical Application Study of Minimally Invasive Double-Reverse Traction in Complex Tibial Plateau Fractures.

The aim of this study was to evaluate the clinical application of double-reverse traction for minimally invasive reduction of complex tibial plateau fractures. A retrospective analysis was performed to identify all patients admitted to the Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, from March 2017 to December 2019 with Schatzker type VI tibial plateau fractures. 12 patients were identified (7 men and 5 women) with an average age of 46.15 ± 13 (39-58) years old. All patients were treated with double-reverse traction and closed reduction. After the fracture was reduced, the bone plate was fixed by percutaneous minimally invasive implantation. Outcomes assessed in this study include operation time and intraoperative blood loss. Imaging was performed during the postoperative follow-up, and functional recovery was evaluated at the final follow-up according to the Hospital for Special Surgery (HSS) score and the International Knee Joint Literature Committee (IKDC) functional score. Patients were followed up for 12.54 ± 1.5 (8-15) months. The average operation time was 63.63 ± 21 (35-120) minutes, and the average intraoperative blood loss was 105.45 ± 21 (60-200) mL. The Rasmussen imaging score was either excellent or good in all cases. The knee joint HSS score was 86.15 ± 6 (79-90) points, and the IKDC score was 80.01 ± 11 (75-90) points. No complications, such as wound infection, incision disunion, loosening of internal fixation, and internal fixation failure, occurred. In the treatment of Schatzker VI type complex tibial plateau fracture, the dual-reverse traction minimally invasive technique has the advantages of safety and effectiveness, less soft tissue injury, and allowing early joint movement, which is worthy of clinical promotion.

Use of Point-of-Care Ultrasound to Identify Occult Fractures of the Tibia in the Pediatric Emergency Department: A Case Series.

BACKGROUND: Although point-of-care ultrasound (POCUS) has been shown to be useful in the identification of both pediatric and adult long-bone fractures in the emergency setting, radiography remains the standard of care. Emergency physicians are often faced with the dilemma of how to evaluate and treat the child with lower leg injury and physical examination concerning for fracture but no readily identifiable fracture line on radiography. CASE REPORTS: We present four cases in which POCUS was used to diagnose a radiographically occult fracture of the proximal tibia in young children. This is the first case series of occult fracture of the tibia diagnosed with POCUS. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS can demonstrate evidence of fracture even after unremarkable radiography is obtained, and POCUS findings consistent with fracture might allow for more effective guidance on discharge.

Closed reduction and locked intramedullary nailing of diaphyseal long bone fractures without intra-operative imaging and fracture table.

PURPOSE: Early closed reduction and locked intramedullary (IM) nailing has become the standard treatment for diaphyseal long bone fractures in high income countries. The low and middle income countries (LMICs) are still lagging behind in transiting from open surgical reduction and non-operative modalities to closed reduction due to lack of requisite equipment. However, some surgeons in LMICs are beginning to achieve closed reduction even without the equipment. METHODS: A prospective descriptive study was done on a total of 251 fresh diaphyseal fractures of the humerus, femur and tibia fixed with a locked nail over a 5½-year period. The fractures were grouped into those that had open reduction, closed reduction or reduction with a finger. RESULTS: Closed reduction was done for 135 (53.8%) fractures belonging to 123 patients. The mean and range of the patients' ages were 41.33 and 13-81 years, respectively. Males constituted 69.9% and mostly (48%) sustained fractures in motorcycle accident. There was a significant negative association between closed reduction and fracture-to-surgery interval (p < 0.001). Closed reduction also had positive associations with: (i) humerus and tibia fractures (p < 0.001), (ii) middle, distal and segmental fractures (p = 0.025), (iii) retrograde approach to femur fracture nailing (p < 0.001), and (iv) wedge or multifragmentary type femur fractures (p = 0.005). CONCLUSION: With constant practice, it is possible to achieve closed reduction of many fresh diaphyseal long bone fractures in spite of the limitations imposed on surgeons in LMICs by poor health systems and grossly inadequate fracture care facilities.

The Likelihood of an Occult Fracture in Skeletal Surveys Obtained in Children More Than 2 Years Old With Concerns of Physical Abuse.

OBJECTIVES: Skeletal surveys are necessary in the evaluation for physical abuse in children less than 2 years old, but when to obtain a skeletal survey in older children is less clear. METHODS: A retrospective study of patients older than 2 years who underwent skeletal survey over a 3-year period after implementation of an electronic health record physical abuse order set was conducted. Data were analyzed using descriptive statistics and compared with data from a cohort before order set implementation. The radiation dose of a skeletal survey in a 5-year old was calculated using a previously published technique. RESULTS: There were 325 skeletal surveys, a marked increase in the rate of skeletal surveys compared with before order set implementation. Less than 2% (6/325) of skeletal surveys demonstrated an occult fracture. Of the 6 patients with occult fractures, 4 were physically abused; in each case, the diagnosis of abuse was evident before the skeletal survey. The other 2 patients fell from windows. The radiation exposure was 0.34 mSv. CONCLUSIONS: The rate of occult fractures on skeletal survey is significantly lower than previously reported. This is likely because our population included all children who underwent skeletal survey and not the subset referred to a child abuse pediatrician. In addition, our data demonstrate that in children older than 2 years, skeletal surveys are unlikely to assist in making a diagnosis of physical abuse. The radiation exposure in a 5-year-old is 70% greater than in an infant, but still a dose, which represents a negligible health risk.

Diagnostic Performance and Advanced Imaging Reduction With Digital Tomosynthesis in Scaphoid Fracture Management.

BACKGROUND: Management of scaphoid fractures often requires advanced imaging to achieve accurate diagnoses and appropriate treatment. Digital tomosynthesis (DTS) is a cross-sectional imaging modality that may be used to substitute magnetic resonance imaging or computed tomographic scans. The purpose of this study is to: (1) determine the diagnostic accuracy of DTS in occult scaphoid fractures; and (2) report on the reduction of other advanced imaging when using DTS. METHODS: From May 2014 to October 2017, the charts of all patients who underwent scaphoid tomogram were retrospectively reviewed. The diagnostic accuracy of DTS for occult fracture was compared with 2-week follow-up plain films. To measure the reduction in utilization of advanced imaging, it was determined whether DTS eliminated the need for advanced imaging by providing adequate information regarding the clinical question. RESULTS: A total of 78 patients underwent scaphoid tomography in this time frame: 39 for occult fracture, 33 for fracture union, 5 for fracture morphology, and 1 for hardware positioning. For the detection of occult fracture, DTS had a sensitivity of 100%, specificity of 83%, positive predictive value of 64%, and negative predictive value of 100%. Advanced imaging was not used in 35 of the remaining 39 patients based on the results obtained by DTS. In patients who did receive advanced imaging, 83% of tomograms provided conclusive diagnostic information. CONCLUSIONS: Digital tomosynthesis increases the diagnostic sensitivity of occult scaphoid fractures, reducing unnecessary immobilization and advanced imaging. Digital tomosynthesis provides clinical detail beyond plain film, which reduces the need to obtain advanced imaging when assessing union, fracture pattern, and hardware placement.

Multislice Spiral Computed Tomography Postprocessing Technology in the Imaging Diagnosis of Extremities and Joints.

OBJECTIVE: To improve the clinical detection rate of bone and joint fractures of the extremities and to explore the value and significance of the application of multislice spiral computed tomography (MSCT) postprocessing technology in diagnosis. METHODS: 80 patients with bone and joint fractures of the extremities admitted to the hospital were selected as the research objects. The patients received X-ray digital radiography (DR) plain film examination and then MSCT examination. At the same time, multiplane reconstruction (MPR) and surface shadow display (SSD) and volume rendering three-dimensional imaging (VRT) technology and other postprocessing technologies compare the differences in the detection rate of limbs and joint fractures between the two inspection methods. RESULTS: A total of 100 fractures were found in 80 patients. The detection rate of X-ray DR was 69%. After MSCT postprocessing technology, the detection rates of MPR, SSD, and VRT were 96%, 98%, and 99%, respectively. The accuracy of MSCT postprocessing technology in diagnosing extremity bone and joint fractures was significantly higher than that of DR, and the difference between groups was statistically significant. CONCLUSION: MSCT postprocessing technology for patients with extremity bone and joint fractures has a good effect. It is not only noninvasive but also has a high detection rate. It can significantly reduce the missed and misdiagnosed rate and provide detailed imaging data for the formulation of clinical treatment plans.

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

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.

Differential diagnosis of acute traumatic hip pain in the elderly.

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.

Evaluation of an Emergency Department High-risk Bruising Screening Protocol.

OBJECTIVES: The objective of this study was to describe the outcomes of implementing a high-risk bruise screening pathway in a pediatric emergency department (ED). METHODS: A retrospective observational study was performed of children aged 0 to <48 months who presented to the ED between December 1, 2016, and April 1, 2019, and had bruising that is high-risk for physical abuse on a nurse screening examination. A high-risk bruise was defined as any bruise if aged <6 months or a bruise to the torso, ears, or neck if aged 6 to <48 months. Records of children with provider-confirmed high-risk bruising were reviewed. RESULTS: Of the 49 726 age-eligible children presenting to the ED, 43 771 (88%) were screened for bruising. Seven hundred eighty-three (1.8%) of those children had positive screen results and 163 (0.4%) had provider-confirmed high-risk bruising. Of the 8635 infants aged <6 months who were screened, 48 (0.6%) had high-risk bruising and 24 of 48 (50%) were classified as cases of likely or definite abuse. Skeletal surveys were performed in 29 of 48 (60%) infants, and 11 of 29 (38%) had occult fracture. Of the 35 136 children aged 6 to <48 months who were screened, 115 of 35 136 (0.3%) had high-risk bruising and 32 of 115 (28%) were classified as cases of likely or definite abuse. CONCLUSIONS: High-risk bruising was rarely present. When infants aged <6 months were evaluated per recommendations, occult fracture was identified in one-third of patients. The screening pathway could help other institutions identify occult injuries in pediatric ED patients.

Negative predictive value of CT for occult fractures of the hip and pelvis with imaging follow-up.

PURPOSE: To determine the negative predictive value of multidetector CT for radiographically occult fracture of the hip or pelvis in an elderly population presenting to the emergency department. METHODS: Two hundred thirty-seven elderly patients with suspected fracture were identified over a 5-year period with negative radiographs acquired in the emergency department followed by an index CT of the hip/pelvis within 24 h. There were 81 cases with a negative index CT, as determined by 2 musculoskeletal radiologists, and with some form of imaging follow-up (MRI, CT, or x-ray) performed within 18 months of the index CT. Follow-up imaging was reviewed by 2 musculoskeletal radiologists for the presence of fracture to determine the performance of the index CT. The electronic medical record was used to exclude the possibility of intervening trauma between the time of the index CT and follow-up imaging. RESULTS: There were 39 cases with follow-up imaging performed within 6 weeks of the negative index CT, and 42 with follow-up imaging within 6 weeks to 18 months of the negative index CT. Eight of 81 patients demonstrated a fracture on follow-up imaging, with 3 of 8 involving the femoral neck or intertrochanteric femur. The negative predictive value of the index CT for the detection of a radiographically occult hip or pelvic fracture was 90.1%. If considering only surgically relevant fractures (femoral neck and intertrochanteric fractures), the negative predictive value improved to 96.3%. CONCLUSION: Computed tomography for occult hip fractures has a high negative predictive value but there are cases not detected with surgical implications.

MRI-only occult geriatric hip fractures: is displacement common with nonoperative treatment?

INTRODUCTION: Although 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. RESULTS: Of 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 EVIDENCE: Level III.