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Should We Operate on Occult Hip Fractures? Guy Rubin MD, Itzik Malka MD and Nimrod Rozen MD Phd

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Should We Operate on Occult Hip Fractures? Guy Rubin MD, Itzik Malka MD and Nimrod Rozen MD Phd CASE CoMMUNICATIONS IMAJ • VOL 12 • MAy 2010 Should We Operate on Occult Hip Fractures? Guy Rubin MD, Itzik Malka MD and Nimrod Rozen MD PhD Department of Orthopedics, HaEmek Medical Center, Afula, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel CT scan was performed [Figure A] and PATIENT 2 KEY WORDS: occult fracture, hip fracture, was interpreted as negative for fracture. An 82 year old male presented to the subcapital hip fracture, He was admitted and a Tc99 bone scan ER with hip pain following a fall the day intertrochanteric fracture was performed showing uptake in the before. Plain X-ray demonstrated a frac- IMAJ 2010; 12: 316–317 intertrochanteric region [Figure B]. We ture of the greater trochanter, with CT discussed the treatment options and scan demonstrating the same fracture. decided that since the patient was able He was admitted and a Tc99 bone scan to ambulate we would not operate. The was performed that showed uptake in ccult hip fractures are well des- patient's follow-up was unremarkable the intertrochanteric region. The patient O cribed in the literature, with the and he was able to walk unassisted. was able to move his leg and to sit. Non- incidence of radiographically occult operative treatment was agreed upon, fracture estimated at 2–9% [1]. When [A] CT coronal view of pelvis. The CT does not and partial weight bearing was obtained an elderly osteoporotic patient presents demonstrate a fracture one week later. After another week the a typical history and clinical presentation patient was walking with minimal of a fall and hip pain, plain radiograph pain and at 2 months follow-up he was should confirm the diagnosis. When the ambulating with no aid. X-ray is interpreted as normal, an occult fracture should be suspected and the LITERATURE REVIEW patient should undergo investigation. All the articles reporting occult hip Several modalities have been proposed fracture discuss the diagnosis strategy such as computed tomography, bone A but not the treatment options. We scan and magnetic resonance imaging, found only six articles describing the which is now the study of choice [2-5]. [B] Tc99 bone scan demonstrating uptake in treatment. Pandey and colleagues [3] The treatment for the occult fracture the intertrochanteric region describe 19 occult hip fractures (14 is not discussed in the literature and subcapital and 5 intertrochanteric); sur- patients undergo conservative or surgical gery was performed on all the patients treatment. In this article we describe two except for one with an intertrochant- cases of occult hip fracture, review the eric fracture due to coexisting medical literature regarding the treatment of this problems. Quinn et al. [2] report 11 kind of fracture and discuss the optional occult hip fractures (5 subcapital and 6 treatments. intertrochanteric) and all their patients underwent surgery except for one with an intertrochanteric fracture that was PATIENT DESCRIPTIONS inoperable because he was not suitable PATIENT 1 surgically. Rubin and team [4] describe An 87 year old man presented to the 12 occult hip fractures (5 subcapital emergency room with hip pain fol- and 7 intertrochanteric), and all the lowing a fall. He was discharged after patients underwent surgery except for plain X-ray failed to demonstrate a one with an intertrochanteric fracture. fracture. Two weeks later he returned In the series of 25 occult hip fractures to the ER because of continued pain (11 subcapital and 14 intertrochant- and ambulation only with assistance. eric) reported by Rizzo et al. [1], all the B patients underwent surgery except for ER = emergency room 4 with intertrochanteric fractures (the 316 IMAJ • VOL 12 • MAy 2010 CASE CoMMUNICATIONS reason was not stated by the author) and ent treatment (hemiarthroplasty or Acknowledgments: managed with partial weight bearing. pinning). This makes surgical treatment We thank Frances N.J Nachmani and Tova Alba and co-authors [5] reported four of the cervical hip fracture the treat- Bick for their help in preparing this manu- neck fractures; one patient was treated ment of choice. Our literature review script for publication. non-operatively with bed rest. revealed that surgery was performed in 97.4% (38/39) of cases with this kind Correspondence: Dr. G. Rubin of fracture. CoMMENT Dept. of Orthopedics, HaEmek Medical Center, The occult intertrochanteric fracture Afula 18101, Israel Occult hip fractures are common and is a non-displaced fracture that is usu- Phone: (972-4) 649-4300 the treating physician should suspect ally more stable than occult subcapital email: [email protected] this type of fracture and be aware of the fracture and displacement does not References modalities to identify this fracture. The change the surgical procedure. We only 1. Rizzo PF, Gould ES, Lyden JP, Asnis SE. Diagnosis literature does not discuss the treatment found a few authors who did not oper- of occult fractures about the hip. J Bone Joint Surg strategy for occult hip fractures, and ate on this type of fracture, mainly due Am 1993; 75: 395-401. surgery seems to be the treatment of to medical problems. Rizzo et al. [1] was 2. Quinn SF, McCarthy JL. Prospective evaluation choice, as for other usual hip fractures, the only author who described partial of patients with suspected hip fractures and indeterminate radiographs – use of Tl-weighted in order to reduce morbidity and mor- weight bearing for these patients. MR images. Radiology 1993; 187: 469-71. tality. We believe that occult hip frac- The goal of hip fracture treatment in 3. Pandey R, McNally E, Ali A, Bulstrode C. tures should be divided into two groups: the adult patient is early mobilization. The role of MRI in the diagnosis of occult hip cervical and intertrochanteric. We suggest the option of conservative fractures. Injury 1998; 29: 61-3. The occult cervical fractures are treatment for patients with occult femo- 4. Rubin SJ, Marquardt JD, Gottlieb RH, Meyers SP, Totterman SM, O'Mara RE. Magnetic resonance non-displaced intraarticular fractures ral intertrochanteric fractures who can imaging: a cost-effective alternative to bone that can easily be displaced. The dis- be ambulated despite the fracture. By so scintigraphy in the evaluation of patients with suspected hip fractures. Skel Radiol 1998; 27: placement of a cervical hip fracture doing the risk of surgical complications 199-204. raises the prevalence of non-union and is obviated and also prevents complica- 5. Alba E, Youngberg R. Occult fractures of the avascular necrosis necessitating differ- tions in a non-ambulated patient. femoral neck. Am J Emerg Med 1992; 10(1): 64-8. Capsule New genetic associations detected in a host response study to hepatitis B vaccine The immune response to hepatitis B vaccination differs in 15 genes (503 normal/295 non-responders). Davila and greatly among individuals, with 5–10% of healthy people co-workers have validated previous findings [HLA-DRA, failing to produce protective levels of antibodies. Several rs5000563, P value combined = 5.57 × 10−10; OR (95%CI) = factors have been implicated in determining this response, 0.61 (0.52–0.71)]. In addition, the researchers detected a chiefly individual genetic variation and age. Aiming to new association outside of the human leukocyte antigen loci identify genes involved in the response to hepatitis B region that passed correction for multiple testing. This SNP is vaccination, a two-stage investigation of 6091 single- in the 3′ downstream region of FOXP1, a transcription factor nucleotide polymorphisms (SNPs) in 914 immune genes involved in B cell development [P value combined = 9.2 × was performed in an Indonesian cohort of 981 individuals 10−6; OR (95%CI)=1.38 (1.2–1.6)].These findings might help showing normal levels of anti-HBs versus 665 individuals us understand the biological reasons behind vaccine failure displaying undetectable levels of anti-HBs 18 months after and other aspects of variation in the immune responses of initial dose of the vaccine. Of 275 SNPs identified in the healthy individuals. first stage (476 normal/372 non-responders) with P < 0.05, Genes Immunity 2010; 11: 232 significant associations were replicated for25 polymorphisms Eitan Israel “An eye for an eye would make the whole world blind” Mahatma Gandhi (1869-1948), political and spiritual leader of India during the Indian independence movement. He was the pioneer of resistance to tyranny through mass civil disobedience, a philosophyfirmly founded on total nonviolence – which led India to independence and inspired movements for civil rights and freedom across the world. 317.
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