OCCULT FEMORAL-NECK FRACTURES IN THE ELDERLY - OPTIMIZATION OF INVESTIGATION

Aims. A relatively common clinical problem is the elderly patient who presents with strong clinical suspicion of femoral neck fracture, but normal initial radiographs. Our aim was to analyse the methods by whic h such a patient was investigated in a large hospital in New Zealand. We wished to determine the cost-effectiveness of current practice, in the light of recent trends overseas, Methods. We retrospectively revie wed the records of 410 patients over 50 years of age presenting acutel y to Auckland Hospital over a 12 month period, in whom trauma hip radi ographs had been requested. We recorded initial radiographical diagnos is, admission or discharge following acute assessment, further radiolo gical investigations, and the time taken to make the final diagnosis. Results. Twenty-five patients with suspected occult femoral neck fract ure underwent further radiological investigation, consisting of plain radiographs, scintigram, and CT, singly or in combination, The final d iagnosis was achieved by repeat radiographs in 10 patients, and by sci ntigraphy in 15 patients. The time to arrive at the final diagnosis wa s on average 9.6 days when the diagnosis was made by radiographs, and 5.3 days when the diagnosis was made by scintigraphy. The overall aver age time taken to achieve the diagnosis was 7.0 days. Conclusions. Our analysis shows that the bed cost is the major expense incurred by the delayed diagnosis of a suspected occult femoral neck fracture. Variou s studies have shown the accuracy of magnetic resonance imaging in the assessment of these fractures. This practice is not yet routinely est ablished throughout New Zealand. However, an urgent MRI study, perform ed at the time of initial assessment could markedly reduce the cost of managing this patient group.