Missed Fractures in casualty Mr. Louay AL-Mouazzen Registrar Trauma & Orthopaedics
Why we miss fractures 1. Failure to take a good history (e.g. mechanism of injury) and physical examination (e.g. most tender spot) before ordering radiographs. 2. Failure to see and re-examine the patients when asked to interpret radiographs, especially when the patients are handed over to another medical officer at the end of shift. 3. Failure to view all films precisely because too many films are taken for one patient e.g. multi-injured patients.
Why we miss fractures 4- Failure to inspect the whole film or view the film as a whole by concentrating immediately on particular areas of the radiograph. 5. Failure to order special views or additional views for fracture. 6. Failure to X-ray both limbs for comparison e.g. supracondylar fractures in children. 7. Failure to remove metal braces or rings before taking radiographs. 8. Failure to ask for seniors opinion when in doubt.
D O HD islocationsO ccult fractureH alf of injuriesmissed
WRIST PA View (R Wrist): 3 smooth arcs along carpals Intercarpal distance < 3 mm
WRIST Lateral View (Right Wrist): Alignment: Smooth articulation of distal radius to lunate, lunate to capitate, and capitate to 3rd metacarpal Scapholunate angle < 30- 60 degrees
WRIST - D SCAPHOLUNATE DISSOCIATION Most common and significant ligamentous injury of wrist. Mechanism: Fall on outstretched hand (FOOSH) X-ray: PA view: >4 mm widening of scapholunate space (“Terry Thomas sign”) PA view: Scaphoid has “signet ring sign” Lateral view: Scapholunate angle > 60 deg
WRIST-D PERILUNATE DISLOCATION Mechanism: Hyperextension of the wrist Xray: Lateral view: Capitate is not vertically aligned with the lunate and radius. PA view: Smooth middle arc alignment of carpal bones is disrupted. Complications: Median nerve injury, SLAC
WRIST-O SCAPHOID FRACTURE 2nd most common fractured bone of the wrist [#1=distal radius] Mechanism: FOOSH Exam: Tenderness to “snuffbox” area of wrist Xray: Normal in up to 20% cases Ulnar deviated AP View Consider obtaining additional scaphoid views
WRIST-H GALEAZZI FRACTURE Distal-third fracture of the radius AND disruption of distal radioulnar joint (DRUJ) Mechanism: FOOSH with forearm hyperpronated X-Rays: Lateral view: Ulna does not overlie radius Lateral view: Ulnar styloid is not aligned with dorsal triquetrum PA view: Ulnar styloid fracture - Widening of DRUJ Complication: Chronic disability when DRUJ disruption is missed > 10 wks
HIP - O O – Acetabular Fractures Get a Judet views or CT
HIP - H PELVIC RING DISRUPTION Because of the inflexible, ring-like structure of the pelvis, pelvic bone injuries are often found in multiples. Beware of subtle rami fractures and sacroiliac dissociation.
FOOT - ANATOMY Bohler’s angle (generated by a line bordering the superior aspect of the posterior calcaneal tuberosity and a line connecting the superior subtalar articular surface and superior aspect of the anterior calcaneal process) normally is 20-40 degrees.
FOOT –O CALCANEUS FRACTURE Most commonly fractured tarsal bone Mechanism: Often from fall on heels from a height Xray: A Bohler’s angle < 20 degrees suggests a fracture. Additional Imaging: Consider obtaining a “calcaneal view” Often requires CT imaging to assess fragments
FOOT - O TALUS FRACTURE Second most commonly fracture tarsal bone The neck is the most common location of a talar fracture. Mechanism: Excessive dorsiflexion of ankle Xray: Can be subtle cortical break on lateral view Complications : Avascular necrosis
FOOT - H CALCANEUS FRACTURES: 10% associated with THORACOLUMBAR FRACTURE Because of load on axial skeleton when landing on the heels
OTHER EMERGENCIES Compartment Syndrome ( leg, forearm, foot, hand, thigh) Knee pain in children , always examine the hips and think about Perthes 4-7 yrs SUFI 7-11
Septic Arthritis - Children Diagnostic clinical guide (Kocher) :4 criteria Not weight bearing Pyrexial (>38.5) Raise WCC >12,000 Raised CRP >40 1 out of 4 3% risk 2 40% 3 93% 4 ~100%