What is the clinical significance of palpable crepitus in hip injuries?

From the Guidelines

Palpable crepitus in hip injuries is a significant clinical finding that warrants immediate medical attention due to its association with serious underlying conditions that can significantly impact morbidity, mortality, and quality of life. The presence of crepitus, a crackling or popping sensation felt under the examining fingers, suggests the presence of air or gas in the soft tissues around the hip joint, which can be a sign of a medical emergency such as necrotizing fasciitis, gas gangrene, or a penetrating injury 1. When evaluating a patient with hip pain, the detection of crepitus should prompt urgent imaging studies such as X-rays or CT scans to confirm the presence and extent of gas in the tissues.

The significance of palpable crepitus in hip injuries can be understood by considering the following key points:

• It indicates a potential medical emergency that requires immediate attention to prevent further complications and improve outcomes 1.
• The underlying conditions associated with crepitus, such as necrotizing fasciitis or gas gangrene, can lead to rapid progression of tissue destruction, systemic toxicity, and potentially life-threatening complications if not addressed promptly.
• The presence of crepitus essentially changes the management approach from conservative to emergent intervention, highlighting the need for urgent surgical consultation, aggressive surgical debridement, broad-spectrum antibiotics, and intensive supportive care.

In the context of hip injuries, the presence of palpable crepitus is a critical factor that influences the management approach, emphasizing the need for prompt and aggressive intervention to mitigate the risk of morbidity, mortality, and long-term quality of life implications 1.

From the Research

Significance of Palpable Crepitis on Hip Injuries

• Palpable crepitis is a significant finding in hip injuries, indicating the presence of a fracture or other underlying condition 2, 3.
• The incidence of hip fractures is decreasing, but the overall prevalence continues to increase due to an aging population, with people older than 65 suffering fractures at a rate of 0.6% per year--2% per year for persons older than 85 2.
• Hip pain can be located anteriorly, laterally, or posteriorly, and diagnosing the cause is important for prescribing effective therapy 4.
• Intra-articular pain is often caused by a labral tear or femoroacetabular impingement in younger adults or osteoarthritis in older adults 4.
• Radiography, ultrasonography, or magnetic resonance imaging may be needed for a definitive diagnosis, with radiography of the hip and pelvis being the initial imaging test 4.
• CT scans can be used to diagnose osteoporosis and are gaining popularity for opportunistic osteoporosis screening by measuring BMD and other bone strength indices 5.
• MRI is a more accurate modality than CT scan for obtaining early diagnosis of occult hip fractures, especially if clinical suspicion remains after a negative CT scan 3, 6.

Diagnostic Approaches

• CT scans are a valid first-line investigation for suspected plain X-ray occult hip fractures 6.
• MRI should be used if clinical suspicion remains after a negative CT scan 6.
• Ultrasound-guided anesthetic injections can aid in the diagnosis of an intra-articular cause of pain 4.

Complications and Associated Conditions

• Osteoporotic vertebral fractures are common in hip fracture patients and are under-recognized 5.
• Femoroacetabular impingement, labral tears, and gluteus medius tendon tears typically have good surgical outcomes, and advanced imaging and/or early referral may improve patient outcomes 4.