In these pressured conditions, it’s no surprise that sometimes injury assessment and X-ray interpretation doesn’t always go to plan. You may have heard of the statistic published in the BMJ in 2002: a study showed that 39 % of ‘clinically significant abnormalities’ on X-rays, were being missed by Junior Doctors.
The problem is, by the time the patient has travelled through the A and E system and left the hospital, they may be falsely reassured that their bottom/trotter/oddly shaped pinkie is osseous-tastic. Expert review of imaging by radiologists sadly doesn’t often happen in real time.
In the best-case scenario, a patient with an initially missed fracture will be alerted a day or two later. In the worst-case scenario, the system breaks down, the patient never gets to hear the truth, and greater harm is caused in the long run.
The first had a high velocity inversion injury (OK, so she was a wee bit tipsy on her hen night), with immediate lateral alveolar swelling, and weight-bearing was horribly painful. She learned this on her honeymoon with a cheery call inviting her to come in to fracture clinic.
Several weeks after being discharged, he’s still wondering why he can ’t sit properly, can ’t walk for more than ten minutes without pain, and isn’t able to climb his trees. Clinically, it really hurt him to hop, his gait was antalgic, and he looked extremely nervous on being asked to carry out a squeeze test.
Give us a call 0208 004 7733 or email us firstname.lastname@example.org, and we’ll get the conversation going! Dr Path Spencer-Smith is a Consultant Physician in Sport and Exercise Medicine and Director of Sport doc London.
A ray is easy to take, and will pick up many fractures, but Beau ... Read More. Foot pain:Stress fractures are very common and show up on ray around 10-14 days after the injury in many patients.
Generally 3 views of the hand are needed to accurately assess the presence or absence of a fracture. A rule of thumb generally used is that if you can bear weight or Wei ... Read More.
There is probably no significant displacement and natural healing has started. Make sure you're using firm fitting supportive footwear with good heels and arches.
US doctors from Duke University warn that relying on standard X-rays alone to give a clean bill of health could lead to wrong diagnoses and lawsuits. Dr Charles Spritzer, who led the research, said: “The diagnosis of traumatic fracture most often begins and ends with X-rays of the hip, pelvis, or both.
In the study of patients complaining of pain after an injury to the hip or pelvis, 13 with normal X-ray findings were found to have a collective total of 23 fractures seen on MRI (magnetic resonance imaging). The researchers say it is worth using MRI as well as an X-ray if doctors are in any doubt, particularly since hip patients tend to be frail and elderly with a higher than average risk of complications and death.
“Use of MRI in patients with a strong clinical suspicion of traumatic injury, but unimpressive X-rays has a substantial advantage in the detection of pelvic and hip fractures.” Dr Tony Nicholson, from the Royal College of Radiologists, said the findings quantified something already known or suspected.
If an elderly patient has persistent pain even though their X-ray shows only minor arthritis, an MRI would be a very reasonable request to check that there is not a fracture. Months after their episode of trauma they still have pain and swelling and have been unable to get back to their sporting activity.
Athletes do need to be aware that x-rays, particularly at the time of the injury and particularly in joints such as the ankle, frequently miss fractures. A bone scan is often used these days to make the diagnosis of bony injury where x-rays are normal but the history and examination findings suggest otherwise.
This requires an injection of a radio isotope dye into the arm which is then taken around the body by the blood stream. Sometimes specific types of imaging (CAT or MRI scans) of the particular area are performed to assess the extent of the damage to the bony and cartilaginous surfaces.
This may allow us to see bony fractures which have become unstable and formed loose bodies in the past. This usually means temporarily removing the athlete from their provocative activity and embarking on an appropriate rehabilitation program before the stress “crack” in the bone becomes anything more major.
Ultrasound scans are also used more and more these days to help determine the nature of soft tissue injuries such as acute or chronic Achilles (bottom of calf), patella (front of knee), tendon injuries and rotator cuff tears in the shoulder. These are a relatively inexpensive form of investigation but can provide very useful information with regard to diagnosis and severity of injury.
The most advanced (and expensive) form of imaging used in sports medicine is the MRI scan. MRI (Magnetic Resonance Imaging) gives the best pictures of the soft tissues available and allows us to see the precise anatomy of muscles and tendons, nerves and blood vessels, amount of fluid in joints as well as bony architecture.
Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. English: So growth plate fractures can occur in any child that has growth plates, which is where you grow from on the ends of the bone, and usually that's kids and adolescents ages up to about 15 to 17.
I mean adults don't have growth plates per se, but are children then more predisposed to fractures, I guess would be the question. Dr. English: I don't know that they're more predisposed to fractures, but there is this thought that the growth plate is a weaker part of the bone and so it is very common to actually get a fracture through the growth plate, especially when kids are growing.
Dr. English: Yeah, and part of the reason that it is very difficult for us to see fractures through the growth plate is because the way that the growth plate looks on in X-ray is the same as fractures look in an adult. In adults, a fracture appears exactly the same way, so it's a dark area amidst a bright white bone.
Dr. Miller: So you have to make this diagnosis many times, I suppose, based on your clinical judgment. So even though we see a dark line amidst a bright white bone, I can say that's a normal appearing growth plate, but if your child is tender directly over that growth plate after an injury that can cause a break, then a lot of times we would diagnose you with what is called a Salter-Harris I, or a growth plate fracture.
Dr. Miller: So I suppose for the parent who takes their child to see a physician, gets an X-ray, and is told that that X-ray is normal, but the child continues to have pain in an area where, you know, they fell or hurt themselves, maybe they should seek additional advice. And I would trust that's the right thing to do, especially for a week or two, until they can follow up and have a repeat examination.
Dr. Miller: So if you make this clinical diagnosis of a fracture in a child, basically would you treat it the same for the same length of time? Dr. English: Yeah, I would definitely treat it for a period of between four and six weeks, depending on where the growth plate fracture is located.
Dr. Miller: So, bottom line, if you have a child that's had an injury say to the wrist or to the leg and that area is painful and swollen, and even if the X-ray appears normal to a radiologist, you might want to have that checked out by another physician, especially a sports med physician or an orthopedist. Enter your email address at thescoperadio.com and click “Sign me up” for updates of our latest episodes.
The Scope Radio is a production of University of Utah Health Sciences. ACUTE musculoskeletal injuries form a significant proportion of the workload in both general practice surgeries and accident and emergency departments.
The consequences of missed diagnosis range from minor pain and inconvenience for patients, to adverse long-term outcomes and chronic functional limitation due to fracture non-union, joint stiffness and the need for later, more complex surgery. Most doctors who have worked in A&E will remember their consultants at some point asking them to “take another look” at a certain patient’s X-ray, gently informing them they have missed a fracture.
In the assessment of upper limb injuries, the history should clarify the site of pain and swelling and any associated loss of function or movement. Missing these often subtle injuries can lead to chronic pain, early osteoarthritis and reduction of hand function.
Examination should elicit signs of bony tenderness, swelling, reduced range of movement and joint laxity. The evaluation of forearm injuries should include a careful examination of both the wrist and elbow joints, as a fracture of one bone can lead to shortening and the resultant dislocation of the other.
If the radius is fractured and shortens, the ulna tends to dislocate at the distal radio-ulnar joint (Gallery injury). In the case of an ulna fracture, the radial head dislocates from the radiocapitellar joint at the elbow (Monteria injury).
These involve obtaining ankle X-rays when a patient has the triad of alveolar pain, tenderness and inability to weight-bear. Knee injury assessment should identify the presence of a haemarthrosis, which the patient will report as immediate swelling in the joint, rather than a reactive effusion taking many hours to develop.
Knowledge of an area’s anatomy and the normal relationships between bones is crucial when interpreting abnormal X-rays. Identifying a major long bone fracture from across the room can be relatively straightforward, however more subtle injuries require a systematic approach to X-ray interpretation.
On the lateral view, a vertical line drawn down the anterior cortex of the humerus should cross the middle third of the capitalism. Furthermore, soft tissue signs, such as a raised anterior fat pad in the elbow, can aid in the diagnosis of subtle fractures.
This occurs because fat is released from a fracture or ligament avulsion and floats on top of blood, which is denser. If a patient suffers a fall, sustaining a hip injury and clinical examination is strongly suggestive of a fracture, a normal X-ray does not exclude the diagnosis.
As per NICE guidelines, they should go on to have further imaging of the injured area in the form of an MRI or CT scan. • Request CT or MRI scans for high-risk areas when a patient appears to have a fracture clinically, but the X-ray looks normal.