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Three Part Question

In [patients with a neck of femur fracture] is [ultrasonography more accurate than plain x-ray or computed tomography] at [detecting a fracture]?

Clinical Scenario

An 80 year-old male presents to the Emergency Department following a fall at home. The nurse reports that the patient is complaining of pain in his right leg, which appears shortened and externally rotated. You wonder whether you can use point of care ultrasound to establish whether he has a fractured neck of femur.

Search Strategy

The EMBASE, CINAHL and Medline databases were searched via the Healthcare Databases Advanced Search Interface.
Search terms were as follows:
[("neck of femur").ti,ab OR ("proximal femur").ti,ab OR ("femoral neck").ti,ab OR ("NOF").ti,ab) OR ("femur").ti,ab OR ("femoral").ti,ab] AND [("fracture").ti,ab OR ("fracture*").ti,ab)] AND [("ultrasound").ti,ab OR ("ultrasonography").ti,ab OR ("ultrason*").ti,ab)] AND [("diagnosis").ti,ab) OR ("diagnostic").ti,ab]

Search Outcome

492 papers were found, of which 490 were irrelevant. Of the two remaining, relevant papers, there was one prospective, blinded, observational study and one case report.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Colon, R. et al 2015 USA	One 81 year- old patient attending the Emergency Department	Case report	Point of care ultrasound (POCUS) accuracy against plain x-ray and CT	POCUS demonstrated a cortical break of the right hip. Plain x-ray was reported as “negative for acute fracture”. CT pelvis and proximal femur showed an oblique fracture through the greater and lesser trochanters	Single patient case study
Huang, V. et al 2019	24 adults presenting to ED with suspected hip fracture	Prospective, blinded, observational	Presence of fracture on ultrasound (fracture site identified, femoral neck haematoma, hip effusion)	Fracture site identified in 2 patients, haematoma present in 8 patients, effusion present in 16 patients	Single centre study. Small number of patients. No power calculations demonstrated.
			Presence of fracture on XR/CT/MRI	13 patients with hip fractures
			Sensitivity of US for hip fractures	100%
			Specificity of US for hip fractures	63.6% (increased to 81.8% when comparing to the unaffected side for asymmetry)
			NPV of US for hip fractures	100%
			PPV of US for hip fractures	76.5%
				2 patients diagnosed with fracture on US which was not present on XR.

Comment(s)

There is a growing body of evidence that point of care ultrasound (POCUS) can be used in the Emergency Department to detect a variety of fractures. Ultrasound evaluation of patients with suspected neck of femur fractures allows for immediate diagnosis on clinical examination. With such patients often experiencing pain as a result of their fracture, the fascia iliaca block (FIB) is a popular choice to provide opioid-sparing analgesia in a largely elderly population. However, the FIB can only be administered once a neck of femur fracture is proven radiologically. If POCUS can accurately demonstrate a neck of femur fracture, the FIB can be administered immediately under ultrasound guidance. The effects of this would be threefold: 1. The patient would rapidly receive targeted analgesia 2. The need for opioid analgesia whilst the patient waits for definitive diagnosis would be reduced 3. Whilst undergoing plain x-ray or advanced imaging, the effects of the FIB would reduce any pain associated with positioning the patient for this imaging.

Clinical Bottom Line

Point of care ultrasound can detect the presence of neck of femur fractures. There is a paucity of evidence to compare its accuracy against standard imaging of the pelvis.

References

1. Colon, R. et al Diagnosis of an Occult Hip Fracture by Point-of-Care-Ultrasound. Journal of Emergency Medicine 2015: pp. 916-919.
2. Huang, V. et al. The diagnostic utility of musculoskeletal ultrasound in evaluating suspected hip fractures in the ED. Clinical Journal of Sport Medicine 2019; pp.156-157.