Hossain M, Barwick C, Sinha A K, Andrew J G
Department of Orthopaedics and Trauma, Ysbyty Gwynedd, Bangor, UK.
Injury. 2007 Oct;38(10):1204-8. doi: 10.1016/j.injury.2007.04.023. Epub 2007 Sep 18.
The possibility of occult hip fracture in older patients after a fall is a common problem in emergency and orthopaedic departments. Magnetic resonance imaging (MRI) scanning is the best investigation, but is expensive and may be difficult to obtain. The value of various clinical signs to determine which patients are at risk of occult hip fracture has not been reported. We reviewed all patients who had MRI scan for suspected hip fractures but had normal initial X-rays over a 6-year period. We identified 76 patients. Twelve patients were excluded. Two patients had MRI scan for suspected stress fracture and two patients had metastatic fractures. Eight patients had inadequate or untraceable clinical notes. Each patient's personal details, mobility, independence and detail clinical details were recorded. Following case review of 64 patients we excluded 5 patients with associated osteoarthritis of the hip joint, 1 patient with fibromyalgia and 1 patient with pre-existing multiple myeloma. Thirty-five patients had occult proximal femoral fractures. Of them four patients had isolated pubic ramus fractures and five patients had isolated greater trochanter fractures. Twenty-two patients had no fracture. The value of the individual tests was evaluated using Fisher exact and chi square analysis; with Bonferroni correction for multiple comparisons (10 tests) p<0.005 was deemed significant. Pain on axial loading of the limb and pre-fracture restricted patient mobility were both associated with the presence of a fracture (p<0.005). Both factors had identical positive predictive value=0.76, a negative predictive value=0.69 and post-test probability of disease given a negative test=0.30. Predictive values remained the same when both factors were considered together. Patients who were independently mobile before the fall and who do not have pain on axial compression of the limb are less likely to have a fracture, but these signs alone or in combination do not exclude a fracture. The clinical signs investigated cannot distinguish between patients with and without a hip fracture, and MRI scanning is necessary to establish whether some patients have an occult fracture.
老年患者跌倒后隐匿性髋部骨折的可能性是急诊科和骨科常见的问题。磁共振成像（MRI）扫描是最佳检查方法，但费用高昂且可能难以进行。尚未有关于各种临床体征对确定哪些患者存在隐匿性髋部骨折风险的价值的报道。我们回顾了6年间所有因疑似髋部骨折进行MRI扫描但初始X线检查正常的患者。我们确定了76例患者。12例患者被排除。2例患者因疑似应力性骨折进行MRI扫描，2例患者有转移性骨折。8例患者的临床记录不完整或无法追溯。记录了每位患者的个人信息、活动能力、独立性及详细临床细节。在对64例患者进行病例复查后，我们排除了5例伴有髋关节骨关节炎的患者、1例纤维肌痛患者和1例既往有多发性骨髓瘤的患者。35例患者有隐匿性股骨近端骨折。其中4例患者有孤立的耻骨支骨折，5例患者有孤立的大转子骨折。22例患者无骨折。使用Fisher精确检验和卡方分析评估各项检查的价值；采用Bonferroni校正进行多重比较（10项检查），p<0.005被视为具有显著性。肢体轴向负荷时疼痛和骨折前患者活动受限均与骨折的存在相关（p<0.005）。这两个因素的阳性预测值均为0.76，阴性预测值均为0.69，检查结果为阴性时疾病的验后概率为0.30。当同时考虑这两个因素时，预测值保持不变。跌倒前能够独立活动且肢体轴向受压时无疼痛的患者发生骨折的可能性较小，但仅凭这些体征单独或联合使用都不能排除骨折。所研究的临床体征无法区分有无髋部骨折的患者。需要进行MRI扫描以确定部分患者是否存在隐匿性骨折。
