Emergency Radiology

, Volume 25, Issue 3, pp 265–273 | Cite as

Computed tomography for occult fractures of the proximal femur, pelvis, and sacrum in clinical practice: single institution, dual-site experience

  • Jacob C. MandellEmail author
  • Michael J. Weaver
  • Bharti Khurana
Original Article



The purpose of this study was to evaluate the diagnostic performance of CT for assessment of occult fractures of the proximal femur, pelvis, and sacrum.

Materials and methods

A retrospective review was performed on patients who received a CT of the hip or pelvis for suspected occult fracture after negative or equivocal radiographs performed within 24 h. The official radiology report was utilized for the determination of CT findings and calculation of sensitivity and specificity. Surgical reports, MRI reports, and clinical follow-up were used as the standard of reference. Sensitivity and specificity were calculated with 95% confidence intervals.


Seventy-four patients received CT of the hip or pelvis for clinical concern for occult fracture after negative or equivocal radiographs. By the reference standard, a total of 40 fractures were present in 25/74 (33.8%) patients, including 35 conservatively treated fractures of the greater trochanter, pelvis, and sacrum, and 5 operatively treated proximal femoral fractures. A total of 14/74 (18.9%) of patients had an MRI within 1 day of CT. MRI identified an operatively treated femoral neck fracture not seen on CT and an operatively treated intertrochanteric fracture, which CT described as a greater trochanteric fracture. There were two false negative conservatively treated pelvic fractures not seen on CT but diagnosed on MRI. On a per-patient basis, CT had an overall sensitivity of 88% (22/25; 95% confidence intervals 69–97%), specificity of 98% (48/49; 95% confidence intervals 89–100%), and negative predictive value of 94%. For the five operative proximal femoral fractures, the sensitivity of CT was 60% (3/5; 95% confidence intervals 15–95%), specificity was 99% (68/69; 95% confidence intervals 92–100%), and negative predictive value was 97%.


In the clinical setting of suspected occult fracture, the sensitivity of clinical CT reports for detection of any type of fracture of the proximal femur, pelvis, or sacrum was 88%. For the small number of operatively treated proximal femoral fractures seen in the study, sensitivity of CT was 60% (3/5) and negative predictive value was 97%, although the relatively few patients needing fixation precludes statistical analysis.


Occult fracture Hip fracture Computed tomography Pelvic fracture Sacral fracture 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Johnell O, Kanis JA (2006) An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 17(12):1726–1733. CrossRefPubMedGoogle Scholar
  2. 2.
    Ly TV, Swiontkowski MF (2014) Chapter 54: Intracapsular hip fractures. In: Browner BD, Jupiter JB, Krettek C, Anderson PA (eds) Skeletal trauma: basic science, management, and reconstruction, 5th edn. Saunders, Philadelphia, pp 1607–1681.e12Google Scholar
  3. 3.
    Evans PD, Wilson C, Lyons K (1994) Comparison of MRI with bone scanning for suspected hip fracture in elderly patients. J Bone Joint Surg Br 76(1):158–159Google Scholar
  4. 4.
    Dominguez S, Liu P, Roberts C, Mandell M, Richman PB (2005) Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial standard radiographs—a study of emergency department patients. Acad Emerg Med 12(4):366–369. PubMedGoogle Scholar
  5. 5.
    Rizzo PF, Gould ES, Lyden JP, Asnis SE (1993) Diagnosis of occult fractures about the hip. Magnetic resonance imaging compared with bone-scanning. J Bone Joint Surg Am 75(3):395–401. CrossRefPubMedGoogle Scholar
  6. 6.
    Kirby MW, Spritzer C (2010) Radiographic detection of hip and pelvic fractures in the emergency department. Am J Roentgenol 194(4):1054–1060. CrossRefGoogle Scholar
  7. 7.
    Bogost GA, Lizerbram EK, Crues JV (1995) MR imaging in evaluation of suspected hip fracture: frequency of unsuspected bone and soft-tissue injury. Radiology 197(1):263–267. CrossRefPubMedGoogle Scholar
  8. 8.
    Verbeeten KM, Hermann KL, Hasselqvist M, Lausten GS, Joergensen P, Jensen CM, Thomsen HS (2005) The advantages of MRI in the detection of occult hip fractures. Eur Radiol 15(1):165–169. CrossRefPubMedGoogle Scholar
  9. 9.
    Peleg K, Rozenfeld M, Radomislensky I, Novikov I, Freedman LS, Israeli A (2014) Policy encouraging earlier hip fracture surgery can decrease the long-term mortality of elderly patients. Injury 45(7):1085–1090. CrossRefPubMedGoogle Scholar
  10. 10.
    Kim KC, Ha YC, Kim TY, Choi JA, Koo KH (2010) Initially missed occult fractures of the proximal femur in elderly patients: implications for need of operation and their morbidity. Arch Orthop Trauma Surg 130(7):915–920. CrossRefPubMedGoogle Scholar
  11. 11.
    Oka M, Monu JUV (2004) Prevalence and patterns of occult hip fractures and mimics revealed by MRI. Am J Roentgenol 182(2):283–288.
  12. 12.
    Hossain M, Barwick C, Sinha AK, Andrew JG (2007) Is magnetic resonance imaging (MRI) necessary to exclude occult hip fracture? Injury 38(10):1204–1208. CrossRefPubMedGoogle Scholar
  13. 13.
    May DA, Purins JL, Smith DK (1996) MR imaging of occult traumatic fractures and muscular injuries of the hip and pelvis in elderly patients. Am J Roentgenol 166(5):1075–1078. CrossRefGoogle Scholar
  14. 14.
    Pandey R, McNally E, Ali A, Bulstrode C (1998) The role of MRI in the diagnosis of occult hip fractures. Injury 29(1):61–63. CrossRefPubMedGoogle Scholar
  15. 15.
    Khurana B, Okanobo H, Ossiani M, Ledbetter S, Dulaimy KA, Sodickson A (2012) Abbreviated MRI for patients presenting to the emergency department with hip pain. Am J Roentgenol 198(6):17–19. CrossRefGoogle Scholar
  16. 16.
    Kellock TT, Nicolaou S, Kim SSY, al-Busaidi S, Louis LJ, O’Connell TW, Ouellette HA, McLaughlin PD (2017) Detection of bone marrow edema in nondisplaced hip fractures: utility of a virtual noncalcium dual-energy CT application. Radiology 284(3):798–805. CrossRefPubMedGoogle Scholar
  17. 17.
    Rehman H, Clement RGE, Perks F, White TO (2016) Imaging of occult hip fractures: CT or MRI? Injury 47(6):1297–1301. CrossRefPubMedGoogle Scholar
  18. 18.
    Thomas RW, Williams HLM, Carpenter EC, Lyons K (2016) The validity of investigating occult hip fractures using multidetector CT. Br J Radiol 89(1060):20150250. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Gill SK, Smith J, Fox R, Chesser TJS (2013) Investigation of occult hip fractures: the use of CT and MRI. Sci World J 2013:10–13. CrossRefGoogle Scholar
  20. 20.
    Heikal S, Riou P, Jones L (2014) The use of computed tomography in identifying radiologically occult hip fractures in the elderly. Ann R Coll Surg Engl 96(3):234–237. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Hakkarinen DK, Banh KV, Hendey GW (2012) Magnetic resonance imaging identifies occult hip fractures missed by 64-slice computed tomography. J Emerg Med 43(2):303–307. CrossRefPubMedGoogle Scholar
  22. 22.
    Haubro M, Stougaard C, Torfing T, Overgaard S (2015) Sensitivity and specificity of CT- and MRI-scanning in evaluation of occult fracture of the proximal femur. Injury 46(8):1557–1561. CrossRefPubMedGoogle Scholar
  23. 23.
    Collin D, Geijer M, Göthlin JH (2016) Computed tomography compared to magnetic resonance imaging in occult or suspect hip fractures. A retrospective study in 44 patients. Eur Radiol 26(11):3932–3938. CrossRefPubMedGoogle Scholar
  24. 24.
    Sadozai Z, Davies R, Warner J (2016) The sensitivity of ct scans in diagnosing occult femoral neck fractures. Injury 47(12):2769–2771. CrossRefPubMedGoogle Scholar
  25. 25.
    Cheung WH, Miclau T, Chow SKH, Yang FF, Alt V (2016) Fracture healing in osteoporotic bone. Injury 47:S21–S26. CrossRefPubMedGoogle Scholar
  26. 26.
    Craig JG, Moed BR, Eyler WR, Van Holsbeeck M (2000) Fractures of the greater trochanter: intertrochanteric extension shown by MR imaging. Skelet Radiol 29(10):572–576. CrossRefGoogle Scholar
  27. 27.
    Reiter M, O’Brien SD, Bui-Mansfield LT, Alderete J (2013) Greater trochanteric fracture with occult intertrochanteric extension. Emerg Radiol 20(5):469–472. CrossRefPubMedGoogle Scholar
  28. 28.
    Chung PH, Kang S, Kim JP, Kim YS, Lee HM, Back IH, Eom KS (2016) Occult intertrochanteric fracture mimicking the fracture of greater trochanter. Hip Pelvis 28(2):112–119. CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Kim S-J, Ahn J, Kim HK, Kim JH (2015) Is magnetic resonance imaging necessary in isolated greater trochanter fracture? A systemic review and pooled analysis. BMC Musculoskelet Disord 16(1):395. CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Dunker D, Collin D, Göthlin JH, Geijer M (2012) High clinical utility of computed tomography compared to radiography in elderly patients with occult hip fracture after low-energy trauma. Emerg Radiol. 19(2):135–9Google Scholar

Copyright information

© American Society of Emergency Radiology 2018

Authors and Affiliations

  1. 1.Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Harvard Medical SchoolBrigham and Women’s HospitalBostonUSA
  2. 2.Department of Orthopedic Surgery, Harvard Medical SchoolBrigham and Women’s HospitalBostonUSA
  3. 3.Department of Radiology, Division of Emergency Radiology, Harvard Medical SchoolBrigham and Women’s HospitalBostonUSA

Personalised recommendations