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EMRad: Can’t Miss Adult Traumatic Hip and Pelvis Injuries

Posted by David Haase, MD on

Have you ever been working a shift at 3 AM and wondered, “Am I missing something? I’ll just splint and instruct the patient to follow up with their PCP in 1 week.” This is a reasonable approach, especially if you’re concerned there could be a fracture. But we can do better. Enter the “Can’t Miss” series: a series organized by body part that will help identify injuries that ideally should not be missed. This list is not meant to be a comprehensive review of each body part, but rather to highlight and improve your sensitivity for these potentially catastrophic injuries. We’ve already covered the adult elbow, wrist, shoulder, ankle/foot, and knee. Now: the hip.

The Hip

  • From the femoral head to generally 5 cm below the lesser trochanter in adults [1].
  • Result in 300,000 hospital visits/year due to hip fractures [2].
  • Hip fractures have significant morbidity and mortality in the elderly.
    • One in five patients with hip fractures dies within one year [2].
  • Surgical delay in hip fractures past 48 hours can double mortality [2,3].

Acetabular Fracture

  • Epidemiology/Importance: Acetabular fractures are relatively uncommon and are created when the femoral head impacts the acetabulum [4]. Associated with high energy trauma such as motor vehicle accidents in the young, or falls in the elderly [4, 5].
  • Symptoms: Pain to their groin or hip and difficulty ambulating [6].
  • Physical Exam: Unless a hip dislocation is present, there will be minimal deformity palpated [6]. The hip may have a limited range of motion. Assess the lower extremity strength and sensation for associated sciatica injury (up to 20%) [6].
  • Diagnostic Imaging: On AP x-ray examine the anterior acetabular wall, posterior acetabular wall, the iliopectineal line, and the ilioischial line for disruption (refer to Figure 1 & 2) [4, 7]. Oblique views (Judet) maximize visualization of the acetabulum. Maintain a low threshold to escalate to CT or MRI in patients with significant hip pain despite negative x-rays.
  • Treatment: Consult orthopedics while in the emergency department for surgical vs non-surgical management [6].

Figure 1: The anterior acetabular wall, posterior acetabular wall (projects lateral to anterior wall), the iliopectineal line (marker of anterior column), the ilioischial line (marker of posterior column), and the acetabular roof. Case courtesy of Andrew Murphy, Radiopaedia.org Annotations by David Haase, MD.

Figure 2: AP pelvis x-ray with acetabular fracture showing disruption of the ilioischial line. Case courtesy of Andrew Murphy, Radiopaedia.org Annotations by David Haase, MD.

Greater Trochanter Fracture

  • Epidemiology/Importance: Uncommon but typically occur with direct trauma in older patients or forceful muscle contraction in younger patients [2]. Greater trochanter fractures often have intertrochanteric extension on MRI [8].
  • Symptoms: Patients report groin or lateral hip pain, may bear weight with a limp [2].
  • Physical Exam: There may be tenderness to palpation at greater trochanter with resistance to range of motion [2].
  • Diagnostic Imaging: X-ray AP and lateral views can usually make the diagnosis [9].
  • Treatment: If truly isolated, non-surgical with non-weight bearing and orthopedic follow up in 1-2 weeks [2]. Consider discussing with Orthopedics in ED if displaced >1 cm as these injuries may require surgery [2].

Figure 3: Greater trochanter fracture. Case courtesy of Dr. Maulik S Patel, Radiopaedia.org Annotations by David Haase, MD.

Superior/Inferior Pubic Ramus Fracture

  • Epidemiology/Importance: Very common stable fracture of the pelvic ring [10]. Often occur from ground-level falls or insufficiency fractures in the elderly. Often associated with posterior pelvic ring fractures [10,11]. Also can be correlated with urethral injuries especially in the setting of posterior pelvic ring involvement [12].
  • Diagnostic Imaging: AP pelvic x-rays are used to evaluate the rami but have a low threshold to evaluate concomitant posterior pelvic ring injury with CT or MRI imaging [9, 10].
  • Treatment: Isolated pubic ramus fractures are nonsurgical, weight-bearing as tolerated, and follow up with Orthopedics/PCP in 1-2 weeks [9,13].

Figure 4: Right superior and inferior pubic rami fractures. Case courtesy of Dr. Henry Knipe, Radiopaedia.org Annotations by David Haase, MD.

Sacral Fracture

  • Epidemiology/Importance: Occur from high energy trauma in younger patients or minor falls and insufficiency fractures in elderly patients [Beckmenn, Santollini]. They are an important site of pelvic neuropathy and radiculopathy [14].
  • Symptoms: The patient may have buttock or low back pain [15].
  • Physical Exam: Sacral area swelling or tenderness. Neurologic signs may be associated [15,16].
  • Diagnostic Imaging: X-rays have poor sensitivity for detecting sacral fractures though inlet and outlet x-rays can provide additional views [14,16]. On AP x-rays one may see arcuate line disruption for longitudinal fractures. For transverse fractures, one may see a paradoxical inlet view on AP x-ray resembling an inlet view x-ray due to an inclination of the proximal upper sacrum [14,15]. If a high index of suspicion, consider CT to diagnose and better characterize a possible injury.
  • Treatment: Discuss with orthopedics as management depends on the fracture pattern or any evidence of neurological injury. Otherwise if deemed stable, may have conservative management with progressive weight-bearing [16].

Figure 5: Left mid sacral ala fracture with an arrow pointing at the region of fracture. Case courtesy of Dr. Ian Bickle, Radiopaedia.org Annotations by David Haase, MD.

Occult Hip Fracture

  • Epidemiology/Importance: Proximal femurs have a high proportion of trabecular bone that makes fractures difficult to detect [3]. Roughly 3 to 4% of plain films will miss hip fractures and a delay in treatment increases mortality [2].
  • Symptoms: Patients often report inability to bear weight or persistent hip or pelvic pain [3].
  • Physical Exam: May find pain with range of motion, axial loading, pain with attempted straight leg raise, and hip tenderness [3].
  • Diagnostic Imaging: AP views should have patients maximally internally rotated to best demonstrate femoral neck. Be sure to assess for disruption of Shenton’s Line [9]. Up to 30% of patients will have “negative” x-rays. If clinical suspicion is high then have a low threshold to obtain CT or MRI, though MRI is considered the gold standard [3, 17, 18].
  • Treatment: Varies depending on fracture type/pattern [19].

Avascular Necrosis of the Femoral Head - AVN

  • Epidemiology/Importance: 10,000 to 20,000 new cases in the United States per year [20]. Necrosis occurs due to insufficient blood supply to the femoral head, commonly occurring with trauma. Patients with sickle cell and collagen diseases particularly are at higher risk [20].
  • Symptoms: Can present with a subtle onset of dull hip pain that progresses to a limp; pain can be days to months after the inciting event [2, 20].
  • Physical Exam: Often with pain on internal rotation and adduction or even passive range of motion [2].
  • Diagnostic Imaging: Radiographic findings include sclerosis surrounding an osteopenic area of the femoral head. This leads to a subchondral fracture found by a crescent lucent subchondral line. This progresses to segmental flattening of the femoral head. If x-rays are negative, MRI is the modality of choice [20].
  • Treatment: Outpatient referral to orthopedics to discuss operative or conservative management [20].

Figure 6: On the superior aspect of the femoral head there is cortical collapse with a linear area of lucency. Also an ill-defined mixed sclerotic and lytic lesion. Case courtesy of Dr. Ivan Turkalj, Radiopaedia.org Annotations by David Haase, MD.

Vertical Shear Pelvic Fracture

  • Epidemiology/Importance: Rare fracture requiring disruption of both the anterior and posterior pelvic ring, usually from high-energy axial loading on one leg such as a fall or motor vehicle accident. Often with other traumatic injuries, including urethral or vascular injuries [21, 22].
  • Symptoms: Pelvic pain.
  • Physical Exam: With tenderness to palpation, the lower extremities may have length discrepancies. Evaluate for ecchymosis and external bleeding including the genital region, and evaluate for neurologic deficits [23].
  • Diagnostic Imaging: X-rays will demonstrate displacement of the hemipelvis, often with pubic symphysis and SI joint disruption [21, 22]. Look for superior displacement of the injured iliac relative to the sacrum (often better seen on inlet/outlet views) [21, 22]. For stable patients, obtain CT imaging to identify posterior lesions and associated abdominal injuries while helping with preoperative planning [22].
  • Treatment: Initially unstable patients can have a pelvic binder applied and will require resuscitation if significant vascular injury including blood products and preperitoneal pelvic packing by surgeons or angioembolization. Will require surgical reduction and fixation [21].

Figure 7: Right pubic symphysis dislocation with sacroiliac joint malalignment, pelvic binder applied. Case courtesy of Dr. Henry Knipe, Radiopaedia.org Annotations by David Haase, MD.

Open Book (Anteroposterior) Pelvic Fracture

  • Epidemiology/Importance: Rare, usually from high energy trauma involving anterior and posterior compression such as motor vehicle accidents or falls [9, 22]. Often with other serious injuries, including visceral organ damage and genitourinary injuries [23].
  • Symptoms: Pelvic pain.
  • Physical Exam: With tenderness to palpation, the lower extremities may be rotated with length discrepancies. Evaluate for ecchymosis and external bleeding including the genital region, and examine for neurologic deficits [23].
  • Diagnostic Imaging: X-rays will show the pubic symphysis disrupted or with vertical fractures through one or both pairs of pelvic rami with more severe injuries causing widening of the SI joint [22]. Note pelvic binders may minimize the disruption seen [22]. CT scan for further detail and to evaluate for associated injuries if the patient is stable [23].
  • Treatment: Pelvic binder and likely requiring resuscitation for blood loss. For active bleeding, angiography for embolization or pelvic packing may be needed. After ensuring thoracic and abdominal bleeding is managed, these fractures are usually treated operatively [24].

Figure 8: Open book pelvic fracture with diastasis of the pubic symphysis and widening of the right SI joint. Case courtesy of Dr. Andrew Dixon, Radiopaedia.org Annotations by David Haase, MD.

Resources

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  2. Stein MJ, Kang C, Ball V. Emergency department evaluation and treatment of acute hip and thigh pain. Emerg Med Clin North Am. 2015 May;33(2):327-43. PMID: 25892725.
  3. Cannon J, Silvestri S, Munro M. Imaging choices in occult hip fracture. J Emerg Med. 2009 Aug;37(2):144-52. PMID: 18963720.
  4. Scheinfeld MH, Dym AA, Spektor M, Avery LL, Dym RJ, Amanatullah DF. Acetabular fractures: what radiologists should know and how 3D CT can aid classification. Radiographics. 2015 Mar-Apr;35(2):555-77. PMID: 25763739.
  5. Laird A, Keating JF. Acetabular fractures: a 16-year prospective epidemiological study. J Bone Joint Surg Br. 2005 Jul;87(7):969-73. PMID: 15972913.
  6. Khodaee, Morteza. Sports-related Fractures, Dislocations and Trauma: Advanced On-and Off-field Management. Springer Nature, 2020.
  7. Lawrence DA, Menn K, Baumgaertner M, Haims AH. Acetabular fractures: anatomic and clinical considerations. AJR Am J Roentgenol. 2013 Sep;201(3):W425-36. PMID: 23971473.
  8. Kim SJ, Ahn J, Kim HK, Kim JH. Is magnetic resonance imaging necessary in isolated greater trochanter fracture? A systemic review and pooled analysis. BMC Musculoskelet Disord. 2015 Dec 24;16:395. PMID: 26704907.
  9. J. Tintinalli (Ed.), Tintinalli’s emergency medicine: a comprehensive study guide (7th edition), McGraw Hill, New York (2011), p. 1930
  10. Studer P, Suhm N, Zappe B, Bless N, Jakob M. Pubic rami fractures in the elderly–a neglected injury? Swiss Med Wkly. 2013 Sep 19;143:w13859. PMID: 24089312.
  11. van Dijk WA, Poeze M, van Helden SH, Brink PR, Verbruggen JP. Ten-year mortality among hospitalised patients with fractures of the pubic rami. Injury. 2010 Apr;41(4):411-4. PMID: 20060970.
  12. Koraitim MM. Pelvic fracture urethral injuries: the unresolved controversy. J Urol. 1999 May;161(5):1433-41. PMID: 10210368.
  13. Krappinger D, Struve P, Schmid R, Kroesslhuber J, Blauth M. Fractures of the pubic rami: a retrospective review of 534 cases. Arch Orthop Trauma Surg. 2009 Dec;129(12):1685-90. PMID: 19629504.
  14. Beckmann NM, Chinapuvvula NR. Sacral fractures: classification and management. Emerg Radiol. 2017 Dec;24(6):605-617. PMID: 28656329.
  15. Santolini E, Kanakaris NK, Giannoudis PV. Sacral fractures: issues, challenges, solutions. EFORT Open Rev. 2020 May 5;5(5):299-311. PMID: 32509335.
  16. Gutierrez-Gomez S, Wahl L, Blecher R, Olewnik Ł, Iwanaga J, Maulucci CM, Dumont AS, Tubbs RS. Sacral fractures: An updated and comprehensive review. Injury. 2021 Mar;52(3):366-375. PMID: 33187674.
  17. Collin, David, Mats Geijer, and Jan H. Göthlin. “Computed tomography compared to magnetic resonance imaging in occult or suspect hip fractures. A retrospective study in 44 patients.” European radiology 26.11 (2016): 3932-3938.
  18. Haubro M, Stougaard C, Torfing T, Overgaard S. Sensitivity and specificity of CT- and MRI-scanning in evaluation of occult fracture of the proximal femur. Injury. 2015 Aug;46(8):1557-61. PMID: 26015154.
  19. Ohishi T, Ito T, Suzuki D, Banno T, Honda Y. Occult hip and pelvic fractures and accompanying muscle injuries around the hip. Arch Orthop Trauma Surg. 2012 Jan;132(1):105-12. PMID: 21874573.
  20. Malizos KN, Karantanas AH, Varitimidis SE, Dailiana ZH, Bargiotas K, Maris T. Osteonecrosis of the femoral head: etiology, imaging and treatment. Eur J Radiol. 2007 Jul;63(1):16-28. PMID: 17555906.
  21. Blum L, Hake ME, Charles R, Conlan T, Rojas D, Martin MT, Mauffrey C. Vertical shear pelvic injury: evaluation, management, and fixation strategies. Int Orthop. 2018 Nov;42(11):2663-2674. PMID: 29582114.
  22. Khurana B, Sheehan SE, Sodickson AD, Weaver MJ. Pelvic ring fractures: what the orthopedic surgeon wants to know. Radiographics. 2014 Sep-Oct;34(5):1317-33. PMID: 25208283.
  23. Durkin A, Sagi HC, Durham R, Flint L. Contemporary management of pelvic fractures. Am J Surg. 2006 Aug;192(2):211-23. PMID: 16860634.
  24. Dyer GS, Vrahas MS. Review of the pathophysiology and acute management of haemorrhage in pelvic fracture. Injury. 2006 Jul;37(7):602-13. PMID: 16309680.

Author information

David Haase, MD

Resident
Department of Emergency Medicine
University of California, Los Angeles

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