Ultrasound diagnosis of non displaced hip fractures Dr Richard Beese Bsc (Hons) MRCP FRCR St Georges Hospital, London

What type of fracture is not visible on x-ray ?

Non displaced fractures Examples : Hip , scaphoid , rib sternum , some facial fractures, toddlers tibia fracture and greater tuberosity humeral fracture All fractures can be non displaced and difficult to see on X-ray

No body wants to miss a bone fracture !

Objectives What are non displaced hip fractures and why are they difficult to diagnose ? Why is it important to diagnose non displaced hip fractures ? How we diagnose non displaced hip fractures. The ultrasound features of fractures and imaging technique.

What are non displaced hip fractures ? Impacted fractures of the neck often in a subcapital position

Impacted fractures of the neck often in a subcapital position

Why are non displaced hip fractures difficult to diagnose ? Not visible on x-ray, because of preservation of shentons line, no fracture line visible , hip trabeculae intact. Patients can weight bare, straight leg raise and demonstrate normal axial compression.

70 year old lady fall onto her right side and admitted with severe right hip pain, failed to mobilise well on the ward , repeat pelvic xray 3 days later.

3 day interval repeat AP pelvis demonstrating a displaced sub capital fracture on the right.

80 year old lady fall onto the right side

75 year old lady fall onto left side. AP pelvis no fracture CT no fracture seen

Why is important to diagnose non displaced hip fractures early? No one wants to miss a fracture and send patients home with a broken hip. Increase immobility and thus morbidity Change of operation from a simple screw fixation to a hemiarthropasty

The ultrasound features of fractures

Rib Ultrasound

Hip fracture ultrasound

Imaging technique

Post traumatic Painful Hip Sonography as a screening test for Occult hip fractures. Ori Safran MD et al Orthopaedic and Radiology Hadassah Hebrew University Medical Centre Jerusalem Israel Journal ultrasound med 2009;28:1447-1452 30 patients ultrasound of both hips compared with MRI. 100% sensitive 65% specific. Concluded, a negative ultrasound can exclude intra articular trauma.

50 year old man RTA left hip pain

Is this new ? Elbow effusions and lipoheamathrosis of the Knee are used to diagnose intra atricular fractures on plain x-ray. Ultrasound is demonstrating ‘ an anterior fat pad sign of the hip’.

Possible pathway in the presence of trauma No bone injury Refer for further Imaging

Conclusion US screening may prevent missing hip fractures in future Screening Ultrasound of the hip in trauma ; Has a short learning curve to become competent. Widely available in A/E and quick to perform at the bedside. Easy to interrupt, comparison both sides. US screening may prevent missing hip fractures in future

Thank you

WHO; 25% of the worlds population have local access to x-rays Ultrasound is being used to differentiate between soft tissue and bone injury in remote austere locations. e.g. Australia and Canada Only 1/3 of patients in Darenth Valley Hospital fracture clinic have a fracture – Huge waste of time and money with immobilisation of soft tissuie injuries. Ultrasound screening could used to improve this.

scaphoid fractures