Skip to main content
SpringerLink
Log in

The patellar pubic percussion test: a simple bedside tool for suspected occult hip fractures

  • Original Paper
  • Published:
International Orthopaedics Aims and scope Submit manuscript

Abstract

Purpose

Patellar finger tapping produces a typical sound that can be detected by a stethoscope positioned on the pubic bone (patellar pubic percussion test (PPPT)). Characteristics of this sound are determined by continuity of bone between patella and pelvis. We hypothesized that a PPPT was able to detect overt hip fractures and occult hip fractures that may not be determined by a standard radiological examination.

Methods

Two independent observers performed a PPPT in patients with a suspected hip or pelvic fracture, just before a conventional radiograph (X-ray) was performed. The PPPT test was scored as negative (similar to contralateral side) or positive (different). Patients with a positive PPPT but with a negative X-ray underwent an additional CT scan.

Results

One hundred and ninety-one patients with suspected hip or pelvic fracture were included. A total of 161 patients (84%) were diagnosed with a fracture (hip, n = 142; pelvic, n = 19). An 85% sensitivity, a 70% specificity, a 0.94 positive predictive value, and a 0.47 negative predictive value of the PTTT were calculated. The inter-observer reliability (kappa) was 0.7. Eleven CT scans as indicated by a mismatch between PPPT (positive) and X-ray (no fracture) identified eight fractures (73%). A multivariate analysis demonstrated that a painful passive movement and the PPPT predicted a hip fracture.

Conclusion

The PPPT is a simple bedside diagnostic tool that is sensitive in detecting clinically straight forward hip fractures as well as occult hip fractures. The PPPT can support decision-making for additional radiological examinations in case of potential occult pelvis or hip fractures.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Lanting LC SC, Hertog PC den, Brugmans MJP (2006) Neemt het aantal mensen met heupfracturen toe of af? Nationaal Kompas Volksgezondheid. www.nationaalkompas.nl

  2. Clough TM (2002) Femoral neck stress fracture: the importance of clinical suspicion and early review. Br J Sports Med 36(4):308–309

    Article  CAS  Google Scholar 

  3. Bowditch H (1846). The Young Stethoscopist, or the Student’s Aid to Auscultation. W.D. Ticknor & Co, Boston

  4. Bache JB, Cross AB (1984) The Barford test. A useful diagnostic sign in fractures of the femoral neck. Practitioner 228(1389):305–308

    CAS  PubMed  Google Scholar 

  5. Carter MC (1983) A reliable sign for the diagnosis of fractures of the hip and pelvis. Orthopedics 6(3):307–308. https://doi.org/10.3928/0147-7447-19830301-03

    Article  CAS  PubMed  Google Scholar 

  6. Peltier LF (1977) The diagnosis of fractures of the hip and femur by auscultatory percussion. Clin Orthop Relat Res 123:9–11

    Google Scholar 

  7. Adams SL, Yarnold PR (1997) Clinical use of the patellar-pubic percussion sign in hip trauma. Am J Emerg Med 15(2):173–175

    Article  CAS  Google Scholar 

  8. Cohen J (1960) A coefficient of agreement for nominal scales. Educ Psychol Meas 20(1):37–46

    Article  Google Scholar 

  9. Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33(1):159–174

    Article  CAS  Google Scholar 

  10. Bottle A, Aylin P (2006) Mortality associated with delay in operation after hip fracture: observational study. BMJ 332(7547):947–951. https://doi.org/10.1136/bmj.38790.468519.55

    Article  PubMed  PubMed Central  Google Scholar 

  11. Novack V, Jotkowitz A, Etzion O, Porath A (2007) Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey. Int J Qual Health Care 19(3):170–176. https://doi.org/10.1093/intqhc/mzm003

    Article  PubMed  Google Scholar 

  12. Pioli G, Lauretani F, Davoli ML, Martini E, Frondini C, Pellicciotti F, Zagatti A, Giordano A, Pedriali I, Nardelli A, Zurlo A, Ferrari A, Lunardelli ML (2012) Older people with hip fracture and IADL disability require earlier surgery. J Gerontol A Biol Sci Med Sci 67(11):1272–1277. https://doi.org/10.1093/gerona/gls097

    Article  PubMed  Google Scholar 

  13. Nyholm AM, Gromov K, Palm H, Brix M, Kallemose T, Troelsen A (2015) Time to surgery is associated with thirty-day and ninety-day mortality after proximal femoral fracture: a retrospective observational study on prospectively collected data from the Danish fracture database collaborators. J Bone Joint Surg Am 97(16):1333–1339. https://doi.org/10.2106/JBJS.O.00029

    Article  PubMed  Google Scholar 

  14. 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. https://doi.org/10.1016/j.injury.2015.05.006

    Article  CAS  PubMed  Google Scholar 

  15. Collin D, Geijer M, Gothlin JH (2016) Computed tomography compared to magnetic resonance imaging in occult or suspect hip fractures. A retrospective study in 44 patients. Eur Radiol. https://doi.org/10.1007/s00330-015-4189-y

    Article  Google Scholar 

  16. Deleanu B, Prejbeanu R, Tsiridis E, Vermesan D, Crisan D, Haragus H, Predescu V, Birsasteanu F (2015) Occult fractures of the proximal femur: imaging diagnosis and management of 82 cases in a regional trauma center. World J Emerg Surg 10:55. https://doi.org/10.1186/s13017-015-0049-y

    Article  PubMed  PubMed Central  Google Scholar 

  17. 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. https://doi.org/10.1016/j.jemermed.2012.01.037

    Article  PubMed  Google Scholar 

  18. Gill SK, Smith J, Fox R, Chesser TJ (2013) Investigation of occult hip fractures: the use of CT and MRI. Sci World J 2013:830319. https://doi.org/10.1155/2013/830319

    Article  CAS  Google Scholar 

  19. 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. https://doi.org/10.1308/003588414X13824511650533

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Lyles KW, Colon-Emeric CS, Magaziner JS, Adachi JD, Pieper CF, Mautalen C, Hyldstrup L, Recknor C, Nordsletten L, Moore KA, Lavecchia C, Zhang J, Mesenbrink P, Hodgson PK, Abrams K, Orloff JJ, Horowitz Z, Eriksen EF, Boonen S, for the HRFT (2007) Zoledronic acid in reducing clinical fracture and mortality after hip fracture. N Engl J Med 357:nihpa40967. https://doi.org/10.1056/NEJMoa074941

    Article  PubMed Central  Google Scholar 

  21. Lloyd BD, Williamson DA, Singh NA, Hansen RD, Diamond TH, Finnegan TP, Allen BJ, Grady JN, Stavrinos TM, Smith EU, Diwan AD, Fiatarone Singh MA (2009) Recurrent and injurious falls in the year following hip fracture: a prospective study of incidence and risk factors from the Sarcopenia and Hip Fracture study. J Gerontol A Biol Sci Med Sci 64(5):599–609. https://doi.org/10.1093/gerona/glp003

    Article  PubMed  Google Scholar 

  22. Tiru M, Goh SH, Low BY (2002) Use of percussion as a screening tool in the diagnosis of occult hip fractures. Singap Med J 43(9):467–469

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Máxima Medical Center, De Run 4600, 5504 DB, Veldhoven, The Netherlands

    Stef Jozef Marie Smeets, Michiel Bernard Winkes, Gerrit Paulus Kuijt, Gerrit Dirk Slooter & Percival Victor van Eerten

  2. Rijnstate, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands

    Wouter Vening

Authors
  1. Stef Jozef Marie Smeets
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Wouter Vening
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michiel Bernard Winkes
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gerrit Paulus Kuijt
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Gerrit Dirk Slooter
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Percival Victor van Eerten
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Stef Jozef Marie Smeets.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Electronic supplementary material

ESM 1

(MOV 8278 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Smeets, S.J.M., Vening, W., Winkes, M.B. et al. The patellar pubic percussion test: a simple bedside tool for suspected occult hip fractures. International Orthopaedics (SICOT) 42, 2521–2524 (2018). https://doi.org/10.1007/s00264-018-4036-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00264-018-4036-2

Keywords

Search

Navigation