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Missed fractures in Emergency Department

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Missed fractures in Emergency Department

  1. 1. Missed Fractures in casualty Mr. Louay AL-Mouazzen Registrar Trauma & Orthopaedics
  2. 2. 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.
  3. 3. 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.
  4. 4. D O HD islocationsO ccult fractureH alf of injuriesmissed
  5. 5. WRIST PA View (R Wrist): 3 smooth arcs along carpals Intercarpal distance < 3 mm
  6. 6. 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
  7. 7. 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
  8. 8. WRIST SCAPHOLUNATE DISSOCIATION
  9. 9. 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
  10. 10. WRIST-D PERILUNATE DISLOCATION
  11. 11. 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
  12. 12. WRIST-O SCAPHOID FRACTURE
  13. 13. 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
  14. 14. WRIST-H GALEAZZI FRACTURE
  15. 15. WRIST-H DISTAL RADIUS FX + CARPAL INJURY
  16. 16. ELBOW anatomy Radiocapitellate line: AP & Lat Anterior humeral line : Lat view Fat pads
  17. 17. ELBOW - D RADIAL HEAD DISLOCATION When identified, must look for a proximal ulnar fracture (see “Monteggia Fracture”)
  18. 18. ELBOW - O RADIAL HEAD FRACTURE
  19. 19. ELBOW - H MONTEGGIA FRACTURE IN CHILDREN
  20. 20. HIP- D D – Hip dislocation ( Ant & Post )
  21. 21. HIP- O O – Femoral Head Fracture ?? CT
  22. 22. HIP - O O – Acetabular Fractures Get a Judet views or CT
  23. 23. 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.
  24. 24. KNEE - H MAISONNEUVE FRACTURE
  25. 25. FOOT - ANATOMY
  26. 26. FOOT - ANATOMY
  27. 27. 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.
  28. 28. FOOT –D LISFRANC INJURY COMPARTMENT SYNDROME
  29. 29. 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
  30. 30. 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
  31. 31. FOOT - H CALCANEUS FRACTURES: 10% associated with THORACOLUMBAR FRACTURE Because of load on axial skeleton when landing on the heels
  32. 32. 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
  33. 33. 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%
  34. 34. Painful Knee Septic Inflammatory OA Soft tissue ( ACL, MM, LM, MCL, LCL) ----- MRI AVN ( SONK, Secondary Osteonecrosis) Patella Dislocation Post TKR Fracture
  35. 35. Questions

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