From the Russell H. Morgan Department of Radiology and Radiological Science, (A.H., J.E., P.T.J., S.D.) Department of Orthopaedic Surgery (A.S.L.), and High Value Practice Academic Alliance (A.H., A.S.R., P.T.J., S.D.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3140D, Baltimore, MD 21287; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (R.K., S.E.S.); Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (A.S.R.); and Library of Evidence, Harvard Medical School, Boston, Mass (R.K., A.S.R.).
Radiology. 2020 Sep;296(3):521-531. doi: 10.1148/radiol.2020192167. Epub 2020 Jul 7.
Background The overall rate of hip fractures not identified on radiographs but that require surgery (ie, surgical hip fractures) remains unclear in elderly patients who are suspected to have such fractures based on clinical findings. Moreover, the importance of advanced imaging in these patients has not been comprehensively assessed. Purpose To estimate the frequency of radiographically occult hip fracture in elderly patients, to define the higher-risk subpopulation, and to determine the diagnostic performance of CT and bone scanning in the detection of occult fractures by using MRI as the reference standard. Materials and Methods A literature search was performed to identify English-language observational studies published from inception to September 27, 2018. Studies were included if patients were clinically suspected to have hip fracture but there was no radiographic evidence of surgical hip fracture (including absence of any definite fracture or only presence of isolated greater trochanter [GT] fracture). The rate of surgical hip fracture was reported in each study in which MRI was used as the reference standard. The pooled rate of occult fracture, diagnostic performance of CT and bone scanning, and strength of evidence (SOE) were assessed. Results Thirty-five studies were identified (2992 patients; mean age, 76.8 years ± 6.0 [standard deviation]; 66% female). The frequency of radiographically occult surgical hip fracture was 39% (1110 of 2835 patients; 95% confidence interval [CI]: 35%, 43%) in studies of patients with no definite radiographic fracture and 92% (134 of 157 patients; 95% CI: 83%, 98%) in studies of patients with radiographic evidence of isolated GT fracture (moderate SOE). The frequency of occult fracture was higher in patients aged at least 80 years (44%, 529 of 1184), those with an equivocal radiographic report (58%, 71 of 126), and those with a history of trauma (41%, 977 of 2370) (moderate SOE). CT and bone scanning yielded comparable diagnostic performance in the detection of radiographically occult hip fracture ( = .67), with a sensitivity of 79% and 87%, respectively (low SOE). Conclusion Elderly patients with acute hip pain and negative or equivocal findings at initial radiography have a high frequency of occult hip fractures. Therefore, the performance of advanced imaging (preferably MRI) may be clinically appropriate in all such patients. © RSNA, 2020
背景 根据临床检查结果疑似髋部骨折的老年患者中，未在 X 线片上发现但需要手术治疗的髋部骨折（即手术性髋部骨折）的总体发生率尚不清楚。此外，尚未全面评估高级影像学在这些患者中的作用。目的 评估疑似髋部骨折但 X 线片未见骨折（包括无明确骨折或仅存在单纯大转子 [GT] 骨折）的老年患者中 X 线片隐匿性髋部骨折的发生率，确定高危亚人群，并通过 MRI 作为参考标准，评估 CT 和骨扫描在检测隐匿性骨折中的诊断性能。材料与方法 检索截至 2018 年 9 月 27 日公开发表的英文观察性研究文献，以确定纳入标准。如果患者根据临床检查疑似髋部骨折但 X 线片未见手术性髋部骨折（包括无明确骨折或仅存在单纯 GT 骨折），则纳入研究。每项研究均报告了以 MRI 作为参考标准的手术性髋部骨折发生率。评估隐匿性骨折的总发生率、CT 和骨扫描的诊断性能以及证据强度（SOE）。结果 共确定 35 项研究（2992 例患者；平均年龄 76.8 岁±6.0[标准差]；66%为女性）。在无明确 X 线片骨折的患者中，X 线片隐匿性手术性髋部骨折的发生率为 39%（2835 例患者中 1110 例；95%置信区间 [CI]：35%，43%），在 X 线片仅显示 GT 骨折的患者中为 92%（157 例患者中 134 例；95%CI：83%，98%）（SOE 为中度）。≥80 岁（44%，1184 例患者中 529 例）、X 线片报告不确定（58%，126 例患者中 71 例）或有创伤史（41%，2370 例患者中 977 例）的患者隐匿性骨折的发生率更高（SOE 为中度）。CT 和骨扫描在检测 X 线片隐匿性髋部骨折方面具有相当的诊断性能（ =.67），灵敏度分别为 79%和 87%（SOE 为低）。结论 急性髋部疼痛且初始 X 线片检查结果阴性或不确定的老年患者中隐匿性髋部骨折的发生率较高。因此，高级影像学（最好是 MRI）的应用在所有这些患者中可能具有临床意义。 © 2020 RSNA
