1. Missed Fractures in
casualty
 Mr. Louay AL-Mouazzen
 Registrar Trauma & Orthopaedics

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. 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. D O H
D islocations
O ccult fracture
H alf of injuries
missed

5. WRIST
 PA View (R Wrist):
 3 smooth arcs along carpals
 Intercarpal distance < 3 mm

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. 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. WRIST
 SCAPHOLUNATE DISSOCIATION

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. WRIST-D
 PERILUNATE DISLOCATION

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. WRIST-O
 SCAPHOID FRACTURE

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. WRIST-H
 GALEAZZI FRACTURE

15. WRIST-H
 DISTAL RADIUS FX + CARPAL
INJURY

16. ELBOW anatomy
 Radiocapitellate line: AP & Lat
 Anterior humeral line : Lat view
 Fat pads

17. ELBOW - D
 RADIAL HEAD DISLOCATION
 When identified, must look for a proximal ulnar
fracture (see “Monteggia Fracture”)

18. ELBOW - O
 RADIAL HEAD FRACTURE

19. ELBOW - H
 MONTEGGIA FRACTURE IN CHILDREN

20. HIP- D
 D – Hip dislocation ( Ant & Post )

21. HIP- O
 O – Femoral Head Fracture ?? CT

22. HIP - O
 O – Acetabular Fractures
 Get a Judet views or CT

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. KNEE - H
 MAISONNEUVE FRACTURE

25. FOOT - ANATOMY

26. FOOT - ANATOMY

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. FOOT –D
 LISFRANC INJURY
 COMPARTMENT SYNDROME

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. 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. FOOT - H
 CALCANEUS FRACTURES:
 10% associated with THORACOLUMBAR
FRACTURE
 Because of load on axial skeleton when landing
on the heels

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. 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. Painful Knee
 Septic
 Inflammatory
 OA
 Soft tissue ( ACL, MM, LM, MCL, LCL) ----- MRI
 AVN ( SONK, Secondary Osteonecrosis)
 Patella Dislocation
 Post TKR
 Fracture

35. Questions