Does Adherence to the Corewell Health-West Occult Hip Fracture Protocol Affect Patient Outcomes?

Document Type

Conference Proceeding

Publication Date

5-9-2025

Abstract

Occult hip fractures (OHFs) are diagnosed on computerized tomography (CT) or magnetic resonance imaging (MRI) after first undergoing negative radiography. OHFs account for approximately 10% of all hip fractures and are associated with poor outcomes due to the higher risk of delayed or missed diagnosis. Hip MRI is generally considered superior to CT in the detection of OHF. Subsequently, our institution recommends MRI as the next diagnostic test after negative radiography in patients with a strong clinical suspicion for hip fractures. Despite these recommendations, MRI is underutilized at our institution for the diagnosis OHF. We intended to evaluate etiologies of MRI underuse and its effect on patient outcomes at our facility.

This is a retrospective study of 130 adult patients presenting to a Level I or Level III Trauma Center from February 17, 2020-January 1, 2024. All patients sustained isolated OHFs and underwent negative or equivocal radiography as their first imaging study. Patients then underwent MRI, computed tomography (CT), or both. Differences in ED dwell time, time to surgery (TTS), length of stay (LOS), and aggregate hospital costs were compared between cohorts who underwent MRI versus CT first. Numeric data was analyzed via ANOVA or Kruskal Wallis methods whereas categorical data was analyzed using Chi-Square or Fishers Exact tests.

12% (16) of patients underwent MRI first and 88% (114) underwent CT first after negative or equivocal radiography. MRI and CT accurately identified OHF in 94% (1 missed fracture) and 96% (4 missed fractures) of cases respectively. There were no significant differences in age (p=0.51), osteoporosis (p=0.41), dementia (p=0.2), osteopenia (p=0.73), interfacility transfer (p=0.2), injury severity (p=0.83) or GCS scores (0.26) between the MRI and CT-first cohorts. Patients who underwent MRI sustained more intertrochanteric fractures (p=0.02). 16 patients in the CT-first group required follow up MRI due to either missed fracture or insufficient information for surgical planning. Patients who underwent MRI first had reduced hospital length of stay (LOS), Emergency Department (ED) dwell time, time to surgery (TTS) and decreased aggregate hospital costs compared to the CT-first cohort, but these changes were not statistically significant (LOS: p=0.36; dwell time: p=0.40; TTS: p=0.13; hospital cost: p=0.37).

Only 12% of patients with OHFs are imaged in accordance with institutional guidelines. Despite perceived efficiency and cost effectiveness of CT compared to MRI among providers, our analysis revealed marked clinically- but not statistically- significantly shorter LOS, ED dwell time, TTS and aggregated hospital costs in the MRI-first group. These observations likely result from 14% of patients in the CT-first group requiring follow up MRI for surgical planning or missed fracture. These results underscore the importance of MRI use in the diagnosis and management of OHF.

Comments

2025 Research Day Corewell Health West, Grand Rapids, MI, May 9, 2025. Abstract 1651

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