title: Occult femoral neck fractures in the elderly: optimisation of investigation.
abstract: OBJECTIVE
  A relatively common clinical problem is the elderly patient who presents with strong clinical suspicion of femoral neck fracture, but normal initial radiographs. Our aim was to analyse the methods by which such a patient was investigated in a large hospital in New Zealand. We wished to determine the cost-effectiveness of current practice, in the light of recent trends overseas.
  
  
  METHODS
  We retrospectively reviewed the records of 410 patients over 50 years of age presenting acutely to Auckland Hospital over a 12 month period, in whom trauma hip radiographs had been requested. We recorded initial radiographical diagnosis, admission or discharge following acute assessment, further radiological investigations, and the time taken to make the final diagnosis.
  
  
  RESULTS
  Twenty-five patients with suspected occult femoral neck fracture underwent further radiological investigation, consisting of plain radiographs, scintigram, and CT, singly or in combination. The final diagnosis was achieved by repeat radiographs in 10 patients, and by scintigraphy in 15 patients. The time to arrive at the final diagnosis was on average 9.6 days when the diagnosis was made by radiographs, and 5.3 days when the diagnosis was made by scintigraphy. The overall average time taken to achieve the diagnosis was 7.0 days.
  
  
  CONCLUSIONS
  Our analysis shows that the bed cost is the major expense incurred by the delayed diagnosis of a suspected occult femoral neck fracture. Various studies have shown the accuracy of magnetic resonance imaging in the assessment of these fractures. This practice is not yet routinely established throughout New Zealand. However, an urgent MRI study, performed at the time of initial assessment could markedly reduce the cost of managing this patient group.
authors.affiliation: Auckland Hospital.
authors.forename: F J
authors.initials: FJ
authors.lastname: Pool
authors.forename: J P
authors.initials: JP
authors.lastname: Crabbe
mesh_terms: D003362:Cost-Benefit Analysis; D003951:Diagnostic Errors; D004636:Emergency Service, Hospital; D005265:Femoral Neck Fractures / Q000000981:diagnostic imaging* / Q000191:economics; D006801:Humans; D008875:Middle Aged; D011859:Radiography; D011877:Radionuclide Imaging; D012189:Retrospective Studies; D013997:Time Factors