ACR Appropriateness Criteria® Acute Hip Pain-Suspected Fracture

Abstract

Acute hip pain following a low-force trauma such as a ground-level fall is a common clinical problem. In the elderly osteoporotic population, this is frequently the result of fractures of the proximal femur or pelvis. As physical examination is often inconclusive, imaging is critical for diagnosis. Radiographs are the preferred first-line imaging modality, although their sensitivity is limited for nondisplaced fractures and further imaging may be necessary as discussed in this article and summarized in the recommendations.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The influence of patient race on the use of diagnostic imaging in United States emergency departments: data from the National Hospital Ambulatory Medical Care survey

“…This may include the ordering of diagnostic imaging exams such as x-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI), or ultrasound. Although guidelines may exist for specific patient presentations [22][23][24], it is often up to the individual physician to decide how to proceed. This subjective assessment process is subject to potential bias that may lead to differential care for minority groups.…”

Endovascular management of pelvic trauma

“…Plain films provide an appropriate first line for assessing pelvic fractures, however, these can be relatively insensitive, particularly in osteoporotic patients (40). Sensitivities of approximately 70% have been reported with particular insensitivity for posterior fractures on anteroposterior pelvic radiographs.…”

Reviewing acute hip fractures in adults

“…26,27 Older adults with osteoporosis are at risk for occult fracture; specifi c risk factors for occult fracture include age over 65 years, low mechanism of injury, and female sex. 28 If initial plain radiographs are negative or equivocal, especially in older adults with persistent hip or groin pain, consider additional imaging modalities.…”

“…8 Several studies have shown that MRI has an accuracy at or near 100%. 25,27,28 A recent study of 1,248 patients by Kellock and colleagues found that CT was 94% sensitive. 29 This is higher than other studies, which found accuracies of CT ranging from 69% to 87%.…”

“…27,30,31 In addition to increased sensitivity, MRI has the added benefi t of lack of radiation as well as providing additional information about surrounding soft tissue injury and fracture morphology that may assist in operative planning and execution. 28 Although MRI is considered the modality of choice in diagnosing radiographically occult proximal femur fractures, CT may be advantageous in certain situations. CT scans are usually more accessible and faster than MRI.…”