Disclosures: Anna M. Weingart: Nothing to disclose

Case Description: The patient is an elderly female who presented with left groin and hip pain for 2 weeks without an inciting event. Initial hip x-rays showed no acute pathology. Her pain was sharp, 10/10, and exacerbated by activity. Examination was suggestive of intra-articular pathology.  

Setting: Outpatient office

Patient: 93-year-old female with left groin and hip pain.

Assessment/Results: Ultrasound of the left hip revealed evidence of discontinuity at the femoral neck with intra-articular effusion and increased Doppler flow with power Doppler imaging (PDI) within the joint capsule. Ultrasound-guided aspiration of the effusion revealed frank blood. Subsequent MRI showed mildly impacted and displaced subcapital left femoral neck fracture with associated reactive marrow edema and joint effusion. Patient was sent to the emergency room and underwent left hip pinning by orthopedic surgery.

Discussion: Although ultrasound with PDI is not part of a routine protocol for detecting hip fractures, it led to accurate diagnosis for this patient. The increased intraarticular Doppler signal seen with PDI reflected the intra-osseous blood flow into the joint capsule. While most hip fractures are detected with plain films, approximately 2-9% have negative or equivocal plain radiography results. Delayed diagnosis of occult hip fracture can result in avascular necrosis, nonunion, loss of function, and even increased mortality. If fracture is suspected, further imaging, such as CT or MRI, is needed. Reports on ultrasound for diagnosis are limited but promising. In a study of 30 patients with hip pain after trauma and inconclusive radiographs, ultrasound had 100% sensitivity and 65% specificity for detecting occult hip fractures. No studies included PDI in this setting which can increase diagnostic efficacy. Ultrasound could be an inexpensive screening tool for patients with suspected occult hip fracture in the office setting.

Conclusion: Ultrasound including PDI in the outpatient setting has potential as a cost-effective, highly sensitive screening tool for occult hip fractures.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/ultrasound-findings-leading-to-the-diagnosis-of-an-occult-left-hip-fracture-in-a-patient-with-negative-x-rays-a-case-report/