Hip fracture is a major public heal...

Hip fracture is a major public health point to be solved [i]or[/i] settled in the United States. (1-3) It follows in hospitalization, disability, and los of independence for an estimated 300000 someones annually in this country. (24) In 1995 alone, medical treatment for this injury, including inpatient care, nursing hearth care, and outpatient services, splendor an estimated $8.68 billion. (2) With the aging of the U population, the number of hip fractures is awaited to increase in the near what may occur hereafter (1,2,5)

Delayed recognition of hip fracture can conclusion in increased morbidity and mortality, as well as a rapid decline in quality of life. One-year mortality rates after this injury range from 15 to 20 percent (1267) Approximately 50 percent of patients who lived independently before sustaining a hip fracture are unable to regain their independent lifestyle; instead, they face ongoing disability and lengthened institutionalization. (2,3) Given these serious results it is vital to discover and appropriately treat patients with hip fracture.

Illustrative Case

A 75-year-old woman readyed to her family physician with persistent left buttock pain for several weeks. Staff at the patient's assisted living facility had noted that in modern weeks she had occasionally limped when walking from her bed to the bathroom. However, she remained able to shower, dres herself, and walk to the main dining latitude and garden.

upon careful review of the patient's history, the physician determined that a fall had not taken place. Aside from mild Alzheimer's disease, the patient was in religious health. Other than the slight limp, her physical examination was normal.

Initial plain-film radiographs of the patient's left hip hinted a possible hip fracture (Figure 1) [T.sub.1]-weighted magnetic resonance imaging (MRI) confirmed the neighborhood of a left nondisplaced femoral neck fracture (Figure 2)

[FIGURES 1-2 OMITTED]

The patient subsequently underwent lay open reduction and internal fixation of the fracture. She had an uncomplicated postoperative course and answered to the assisted living facility.

Clinical Presentation of Hip Fracture

The typical patient with hip fracture is many times an elderly woman with dementia who sustains a fall, may complain of methodical hip pain, and is unable to walk. The physical examination commonly reveals an abducted and externally rotated hip with leg-length discrepancy. The patient usually has localized tendernes athwart the hip and limited range of motion of the affected limb during attempts at passive and active rotation and flexion. Radiographs clearly demonstrate the fracture.

In an instances, however, patients with hip fracture have normal ambulation and complain simply of vague pain in their buttocks, knee thighs, groin, or back. These patients as a common thing [i]or[/i] matter report no antecedent trauma, particularly if cognitive impairment is quick in emergencies Their physical examination, including assessments of active, passive, and resisted motions of the affected hip joint and limb, may be normal. They many times have additional injuries (e.g., scalp lacerations, knee sprains, or other impairments) that mask the hip pathology and direct the physician's attention away from the diagnosis of hip fracture.

Diagnostic Imaging

The diagnosis of hip fracture can usually be established with a detailed history, a thorough physical examination, and plain-film radiographs of the symptomatic hip. If radiographic findings are indeterminate if it be not that suspicious for a hip fracture, other imaging modalities can be useful in confirming the diagnosis.

Various nonrandomized, observational studies have shown that bone scanning of the hip using technetium Tc 99m polyphosphate as the radiopharmaceutical can be up to 98 percent sensitive in confirming the personality of hip fracture when initial radiographic findings are normal or indeterminate. (8-10) The now passing recommendation is to delay scanning for up to 72 hours to optimize the chance of detecting the fracture. (11) [Evidence horizontal C, consensus/expert guidelines] In in the same state [i]or[/i] condition cases, patients may be admitted to the hospital, treated with bed quietness and reevaluated in two to three days.

Various studies also have demonstrated the efficacy of MRI in diagnosing hip fractures. (12-19) single prospective study showed that coronal [T.sub.1]-weighted hip MRI was 100 percent sensitive in confirming the carriage of hip fracture in patients with indeterminate findings upon initial plain-film radiographs. (17) [Evidence of the same height B, nonrandomized study] The authors of the studious mood concluded that MRI is more accurate and probably les expensive than other imaging alternatives (i.e., bone scanning and comput tomographic [CT] scanning), especially if consideration is given to the fact that earlier detection flows in faster recovery and shorter hospital stays. In this contemplation the estimated total charges were $448 for MRI, $455 for bone scanning, and $797 for CT scanning.

Other cited advantages of MRI from one side of to the other bone scanning or CT scanning include its ability to expose fractures within 24 hours and its noninvasive nature (i.e., no prospect to ionizing radiation).11,14 The decision to use bone scanning or MRI largely hangs on the availability of these technologies at a given medical facility and the choice of the treating physician. If these resources are not available, the physician should hold a conference with an orthopedic surgeon to decide which imaging modalities should be used.