Imaging protocol may help prevent missed femoral neck fractures

Rate of missed injuries dropped from 57% to 6% with addition of radiographs and CT scans.

Issue: December 2004

HOLLYWOOD, Fla. — A substantial number of femoral neck fractures can be diagnosed earlier if an imaging protocol is followed specifically looking for these injuries. Femoral neck fractures occur in 1% to 9% of patients with femoral shaft fractures; they are typically high-energy injuries and are often associated with comminuted shafts.

“The impetus of this was a one-year review that I did on our own series at our hospital of 82 [femoral shaft] fractures,” said Paul Tornetta III, MD, of Boston University Medical Center, at the Orthopaedic Trauma Association 20th Annual Meeting in Hollywood, Fla. “We had seven femoral neck fractures, of which four, or 57%, were not identified at the time of the initial operative setting. Three of these four required a return to the operating room.” Tornetta is a member of the Trauma Section of Orthopedics Today’s Editorial Board.

Tornetta said that while some of the fractures in that review could have been iatrogenic, most were probably present at the time of injury. Complications associated with a hip (femoral neck) fracture are much more severe than complications associated with a femoral shaft fracture, so if a neck fracture is found it will be the factor that determines treatment.

Best practice protocol developed

“We looked very carefully at the ones that were missed at our own institution,” he said. “There was no consistent assessment used, no particular radiographs were required to get to the operating room, there was no protocol, and on the basis of that my partner and I developed a best practice protocol.”

“We’ve used a very specific protocol, which has decreased our missed injuries from 57% to 6% with the same surgeons doing the cases.”
— Paul Tornetta

A consecutive series of patients with 268 femoral shaft fractures were seen and underwent a new imaging protocol. Of those, 254 were followed for at least one month. The protocol included a preoperative assessment with a dedicated internal rotation plain radiograph of the hip and a fine-cut CT scan through the femoral neck. An intraoperative fluoroscopic or radiographic lateral image was also taken, and postoperatively, an AP and a lateral dedicated view of the hip were taken prior to awakening the patient. The postoperative images should find iatrogenic fractures that may have occurred.

Tornetta said that this protocol can be implemented without the addition of too many resources. “I think the addition of several CT cuts of the femoral neck during the already obtained trauma CT scan is the most important, and it really adds little to cost and no time at all,” he told Orthopedics Today. “The postoperative radiographs in the OR are also important, but most surgeons would get them at some point anyway. My belief is to do them in the OR after the case rather than obtain them after leaving the room.”

19 femoral neck fractures

There were 19 femoral neck fractures diagnosed, of which three were referred for that problem and “don’t really count,” according to Tornetta. Of the 16 remaining fractures, 13 were slightly displaced, two were displaced, and one was determined to be iatrogenic. One injury was missed, although the protocol was followed accurately. Thirteen fractures were diagnosed prior to leaving the operating room; 12 were readily visible on the CT scan.

“So in conclusion we’ve used a very specific protocol, which has decreased our missed injuries from 57% to 6% with the same surgeons doing the cases,” Tornetta said. “This includes dedicated preoperative plain films of the hip, a fine-cut CT of the femoral neck, and postoperative dedicated films of the hip prior to leaving the operating room.”

For more information:

Tornetta P, Creevy WR, Kain M. Avoiding missed femoral neck fractures: improvement by using a standard protocol in cases of femoral neck fractures. #49. Presented at the Orthopaedic Trauma Association 20th Annual Meeting. Hollywood, Fla.