“To err is human, to forgive divine.” Alexander Pope

An Essay on Criticism (1711)

IT WOULD BE NICE if we radiologists could recall this famous phrase and use it as a partial excuse when confronted with a fracture we had overlooked. That our mistakes live to haunt us is one of the drawbacks or strengths of radiology, depending on one’s perspective. It is never pleasant to be reminded of a mis- judgment, but without this we probably would not learn at all.

The specialty of trauma is an important aspect of every prac- ticing radiologist’s career. Accidents comprise a large portion of medical care, and the roentgen examination is the mainstay of diagnosis and subsequent therapy in the majority of patients. Therefore, an awareness of some of the potential pitfalls in frac- ture diagnosis is imperative for good patient care. Furthermore, a large proportion of medicolegal actions result from failure to identify a fracture or dislocation. A recent survey of malpractice claims by the St. Paul Fire and Marine Insurance Company from October, 1973, through October, 1980, showed that one quarter of the claims were due to “failure to diagnose,” and about 5% to failure to diagnose fractures or dislocations.’

This monograph is an attempt to present some common and unusual potential pitfalls in fracture diagnosis in trauma. The majority of the cases are derived from the experience of one of us (H.O. Riddervold) as the emergency room radiologist at the University of Virginia. For years he has supervised the radiol- ogy residents’ coverage of the emergency room, and a significant amount of this material has been learned the hard way-from discovering that someone had made a mistake that was uncov- ered in subsequent double-reading.

We begin by discussing a few general principles of trauma ra- diography. First, the radiologist cannot practice his specialty in a vacuum. This is true for all of radiology and especially true for the subspecialty of trauma. Proper patient care requires a full knowledge of the clinical situation and the utmost cooperation of the consulting clinician. Often the completion of the x-ray re- quest is a chore relegated to someone who may not have even seen the patient. In fact, many of our clinical colleagues feel that physical examination findings are unimportant in accurate roentgen interpretation.

However, adequate evaluation of radiographs requires a thor- ough knowledge of the mechanism of injury, the patient’s symp- toms, and the appropriate physical findings. Without these, one is more likely to overlook subtle pathology which, in many cases, can alter management. Often, if the clinical data is insuf-

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Ftg 2.-A, close-up view of lateral skull film of 40-year old patient following auto accident was interpreted initially as hyperostosis frontalis interna. B, subsequent tomography the following day showed a depressed frontal skull fracture.

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ficient or the radiograph nondiagnostic, we examine the patient before he leaves the x-ray suite. We have also started routinely using ink stamps for certain anatomical areas (Fig 1). The tech- nician marks the stamp in the region where the patient hurts for future reference by the radiologist.

Secondly, the technique used in the radiographic evaluation of the patient is very important in avoiding mistakes. Institutions vary in which standard views are routinely obtained in trauma. There are several treatises on the subject and anyone with spe- cific questions should consult them for an overview of recom- mended techniques.2* ’ Often the number and type of views in a certain clinical situation should be determined in consultation with the specialty involved. This interdisciplinary cooperation is integral to the practice of good trauma radiology.

It is also important to remember that in the setting of trauma, vital information can often lurk in the periphery of a radiograph outside the area of clinical symptoms or primary concern of the radiologist. We have termed these findings “corner c1ues.“4 This information may not always point to acute injury but may suggest underlying disease processes not suspected clinically. Therefore, anyone reading trauma films should make a routine of looking in the corners of an x-ray for this sometimes vital information.

Finally, in many cases, true pathology can be difficult to sep- arate from normal variation. Reference to An Atlas of Normd Roentgen Variants That May Simulate Disease, by Dr. Theodore E. Keats,6 and other similar texts6 can often be helpful in such circumstances.

THE SKULL

The skull is commonly injured in trauma, particularly in au- tomobile accidents. The plain radiograph was once the sole method of evaluating the calvarium. However, the indications for its use have progressively been modified’s ’ as computerized tomography (CT) has become the mainstay in defining injury to the intracranial contents.‘. lo We use CT if there is a suspicion of intracranial injury. However, we have found plain films im- portant in delineating nondepressed skull fractures that CT missed.

By far, the most important single view of the skull is the brow-up lateral projection. This may show air fluid levels in the maxillary sinus, which may indicate injury to the bony struc- tures of the antrum. In this area, the El Gamma1 view described in 1969 may be helpful in diagnosing fractures of the posterior superior wall of the maxillary antrum.” The brow-up lateral skull may also show air fluid levels in the sphenoid sinus, which

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Fig &-A, brow-up lateral skull film of a 16year-old patient involved in auto accident shows an air-fluid level in maxillary sinus(double arrows) and sphenoid sinus (sing/e arrow). B, subsequent CT scan showed intraventricular hemorrhage. Air-fluid levels in sphenoid sinus may suggest serious intracranial injury (see text).

can be highly suggestive of a basilar skull fracture or possible severe intracranial injury. Unfortunately, the identical finding can be seen in nosebleeds or sphenoid sinusitis. Furthermore, the upper cervical vertebrae are commonly included in this lat- eral view and should be scrutinized for unsuspected “corner” pa- thology (Figs 2-4).

THE CERVICAL SPINE Traumatic cervical spine injuries are some of the most life-

threatening situations and x-rays may be difficult to interpret in this setting. However, there are a number of treatises on the subject.12-14 When the patient arrives in the x-ray department, he most likely will have his head and cervical spine immobilized with a cervical collar or other similar devices. This makes thor- ough physical examination of this area more difficult. The most important initial radiographic evaluation is obtained by means of a well-positioned, adequately penetrated, cross-table brow-up lateral view of the cervical spine in the neutral position. It is imperative to see all seven cervical vertebrae and the upper tho- racic vertebrae in any acutely injured patient before moving them and this may require the swimmer’s projection or traction on the shoulders (see following cases>. It is also important to

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FM Gamrr

4.-A, brow-up lateral of 24-year-old patient kicked in the face by i an air-fluid level in maxillary sinus (arrow) missed on original filn lal view of skull (see text for reference) shows fracture of lateral wi ary sinus (arrow).

a horse 1s. B, El all of left

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Fig 5.-A, brow-up lateral view of cervical spine in Wyear-old man involved in accident. Anterior subluxation of C4 on C5, no fracture, cervical spondylosis, and congenital fusion of C2-C3 were noted. Patient was neurologically intact. B, be- cause of continued pain and subluxation, tomography was performed. Fracture of odontoid was demonstrated (arrow). Tomography is important in cervical spine trauma (see text).

Fig 7.-A, neutral position lateral C-spine on 17-year-old patient involved in au- tomobile accident. Small chip fracture off anterior inferior surface of C2 (arrow) and 2 mm of anterior subluxation of C4 on C5 were noted. 6, tomography in anteropos- terior and lateral projection revealed four other fractures. This linear fracture through the body of C2 is one of them. This stresses the importance of tomography in delin- eating the extent of known fractures and that fractures at multiple levels are not uncommon (see text).

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Fig 6.-A, lateral brow-up cervical spine on 40-year-old man in automobile ac- cident shows no abnormality. B, because of pain, flexion view was obtained. Un- suspected Hangman’s fracture of C2 was demonstrated. Flexion-extension views can be invaluable in subtle pathology or in the appropriate clinical setting. In this situation, the patient must move his head himself (see text).

Ftg 8.-A, brow-up lateral C-spine on 12-year-d child hit by truck. C- spine is normal. Note, however, unsuspected parletal skull fracture lurking in comer (arrow) (retouched for detail). 8, lateral skull view confirms presence of fracture. Always look for “comer clues” (see text).

know which combinations of injury commonly occur in the cer- vical spine to realize that multiple fractures or dislocations may be present.15’ l6

If the plain films are normal or nondiagnostic, flexion-exten- sion views may often be helpful in showing ligamentous injury or bony pathology unsuspected in the neutral view. With flex- ion-extension views, the patient must move his head himself to avoid possible damage to the spinal cord. Furthermore, if the

Ftg 8.--A, oblique C-spine WI :-&a with closed head injury. Cen normal but clinically unsuspected fracture’of the mandible was initially missed (arrow). B, panorex confirms “corner” fracture.

Fig 10.-A, lateral C-spine of 66year-old patient with ankylosing spondylitis who fell down stairs. Upper border of C7 is seen; no fracture was identified. B, lateral tomography the following day showed no fracture. Only lower border of C6 is seen. C, repeat lateral tomography three weeks later because of continued pain shows 17 mm of anterior subluxation of C7 on Tl . Fortunately, the patient was still essentially neurologically intact. Lower cervical and upper thoracic vertebrae should be seen in all cases of suspected cervical spine trauma.

clinical suspicion is high, tomography may show fractures when the routine films show no abnormality. Tomography should also be performed to determine the exact extent of injuries evident on plain films.‘7’1a We have found soft tissue changes, such as prevertebral soft tissue swelling, of little value in the acute set- ting. However, its presence should lead one to look more closely for subtle pathology. (CT has been advocated in cervical spine trauma,l’ but our experience with this modality is lim ited.)

Finally, the upper cervical spine is an area fraught with a wide variety of normal variation, and reference to standard texts on the subject can be helpful in the appropriate setting (Figs 5- 10).

THE THORACIC AND LUMBAR SPINE In the trauma setting, patients suspected of having injuries to

the thoracic-lumbar spine will also probably be immobilized. Therefore, we routinely obtain cross-table horizontal beam lat- eral projections of each area without moving the patient. This view allows us to evaluate for gross fracture or subluxation that m ight necessitate immediate therapy. If such an abnormality is present, we then perform tomography in both the lateral and anteroposterior CAP) projections.

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Fig Il.-A, supine chest film of a 28-year-old patient involved in automobile accident. Paravettebral soft tissue swelling in lower dorsal area was initially missed (arrow). 6, lateral thoracic spine view shows mild compression fractures of TQ, Tl 0, and T12 (arrows). Note blurring of lung tissue and ribs by quiet breathing during exposure (see text).

Flg X3.-Lateral lumbar spine film of 26year-old patient involved in automobile accident initially interpreted as normal. Compression fracture of T12 was hidden behind upper viewbox film holder (arrow). Be sure to look at all information on film.

In the thoracic spine, we like to have the patient breathe qui- etly during exposure for the lateral view. This maneuver gives us a tomographic effect with blurring of the lung structures and allows for better bony detail. In the Ap projection, soft tissue swelling adjacent to the vertebrae may be the first clue to a sub- tle compression fracture difficult to see in the lateral projection.

In our cross-table view of the lumbar spine, we have found it helpful to use a long (H-inch by 17-inch) film . This shows us the lower dorsal vertebrae in all suspected injuries to the lumbar spine. There have been many instances where lower thoracic in- jury was interpreted clinically as lumbar injury. Furthermore, we have found instances of sacral injury when lumbar pathology was expected clinically. So one should always look in these two areas in patients with lumbar trauma (see following cases>.

As in the cervical spine, flexion-extension views with the pa- tient moving himself may be valuable in detecting ligamentous injury. Also, multiple level involvement in these two areas is

Fig 12.-A, lateral lumbar spine on 48-year-old man with acute flexion injury. Highest level seen is upper aspect of Ll. 8, close-up lateral thoracic spine shows compression fracture of T12. Thoracic spine injury may present as pain referred to lumbar area. Use of longer film (11 inch x 17 inch) and making sure the lower dorsal vertebrae are seen can avoid such potential mistakes.

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Flg 14.-A, sacral view of Z-year-old patient with clinically suspected sacral injury shows sacral fracture (arrow). B, lateral lumbar spine with long film of patient with sacral fracture shows compression fracture of T12 (arrow) missed on initial interpretation. This stresses the importance of looking for other fractures when one is seen.

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Flg 15.-AP view of lumbar spine on 34-year-old patient thrown out of car shows localized small bowel ileus. Fracture of transverse process of L12 (arrow) was ini- tially missed. Localized ileus can be a secondary sign of bony trauma.

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Flg 16.-AP thoracic spine view on 16-year-old patient involved in automobile accident. Fractures of posterior aspects of eighth, ninth, and tenth ribs were best seen on this view (arrows). Always look at all information provided on films in trauma.

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Flg 17.-A, posterior view of nuclear bone scan in 16-year-old patient who fell on ice ten months earlier shows “hot” spot at L3. B, lateral lumbar spine taken one week before nuclear scan initially read as normal. Review of radiograph after nuclear scan revealed spondylolysis (arrow). In certain patients special studies may be re- quired to delineate subtle pathology (see text).

not uncommon. A good rule of thumb, regardless of the anatom- ical area, is that if one fracture is seen, look even harder for another.

Finally, CT and nuclear scinti$aphy have been used by some to evaluate trauma to the spine’ (Figs ll- 17).

THE CHEST

The chest is one of the most difficult areas to interpret in trauma. There is a wealth of potential information on each film and meticulous attention to detail is imperative in the radio- graphic evaluation of the bony structures.

Always remember to check for soft tissue swelling adjacent to the thoracic vertebrae, which may indicate compression frac- tures of this area. Fractures of the sternum are notoriously dif- ficult to diagnose and in the proper setting overpenetrated lat- eral views may show this injury (see following case).

Importantly, with sternal fractures and injuries to the first 19

Ftg 18.-A, anteroposterior chest film of a 35year-old woman involved in auto- mobile accident initially read as normal. Mild asymmetry of medial ends of clavicles was not seen. B, stemoclavicular view shows dislocation of left sternoclavicular joint.

Fig lg.-Supine chest film of a 15year-old patient involved in automobile acci- dent. Multiple rib fractures on right were seen (arrowheads). Left humeral fracture (arrow) was initially missed until later. This film stresses the importance of looking in corners of chest films.

Fig 20.-L&, lateral chest film of a 26-year-old patient involved in automobile accident. There are mild compression fractures of T6 through T9. Right, close-up lateral shows fracture of sternum (arrow) not appreciated on lateral chest film. These fractures are often associated with significant damage to great vessels (see text).

Flg 21. -A, supine chest film of a i6-month-old infant involved in motor vehicle accident. No fractures were seen. B, right humeral fracture, which was in retrospect in right upper corner of chest film (arrow), was hidden by date label on original film.

Fig 22.-A, left clavicle view of a 67-year-old woman with pain after fail. No fracture was seen. B, lordotic view of left clavicle shows fracture of medial aspect (arrow). This stresses importance of appropriate technique in evaluating trauma.

rib, a close inspection for evidence of damage to the aortic arch and great vessels is imperative.21

The corners of a chest radiograph may show clinically unsus- pected pathology, and the radiologist must make a concerted ef- fort to look in these areas (Figs 18-22).

THE UPPER EXTREMITY

The upper extremity is commonly injured, particularly in sports and recreational activities. The types of injury suspected radiographically are influenced greatly by the mechanism of in- jury and the exact clinical findings, so this data is imperative for adequate roentgen interpretation.

Injury to the shoulder may be difficult to evaluate, particu- larly if the patient is in severe pain. In suspected dislocations,

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Fig 23.-A, right shoulder view of 31-year-old patient thrown out of car read as normal. B, axillary view of same shoulder shows fractured coracoid process (arrow) not seen on routfne views. Special views are sometimes needed to show abnormal- IA:-- I^-^ .-.a\

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Fig 24.-Right shoulder view of 35-year-old patient involved in auto injury. Right shoulder is normal but there is a pneumothorax (arrow) and a fracture of the right second rib (armwhead). Make use of all the information on film (see text).

Fig 25.-Right shoulder view on 21-year-old involved in motorcycle accident. There are fractures of the right coracoid process, right acromion (arrow), and distal right clavicle. Apical pneumothorax is also present. This emphasizes that one should look for all the fractures on the film.

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Fig 26.-A, upper extremity view on 63-year-old patient with seizures and arm pain interpreted as normal. 8, axillary view of same patient seven weeks later shows posterior dislocation that was probably present earlier. Patient was bedridden and aphasic and this made clinical examination difficult. Posterior dislocations may be difficult to diagnose without axillary view, tangential view of glenoid, or fluoros- copy (retouched for detail).

the anterior type usually presents no diagnostic challenge, as the humeral head is usually displaced downward and medially on the AP shoulder view. However, posterior dislocations may be very difficult to diagnose. With this injury, the technologist may take an internal and external rotation AP humerus with both views looking identical. The technologist may also report that the patient cannot move his arm for different projections. In this situation, one should highly suspect posterior dislocation and obtain an axillary view. This projection can usually define the type of dislocation. However, if this view cannot be obtained or if there are still questions, fluoroscopy may be necessary to solve this diagnostic challenge.

In suspected acromioclavicular (AC) joint separation, weight- bearing views can be helpful. However, the weights must be sus- pended from the wrist and not held by the patient. When the patient holds the weights he may compensate for the pain and

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Fig 27.-Fat fluid level (arrow) in shoulder of 24-year-old patient with anterior dislocation. Such a finding is indirect evidence of fracture. In dislocations, postre- duction films should always be done, since fractures may only show up on these projections.

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Fig 28.- A, lateral view of elbow of three-year-old child who fell from swing shows massive joint effusion and questionable supracondylar fracture. The anterior humeral line should normally intersect half of the capitellum and does not do so in this case? 6, AP view of same elbow shows a definite fracture line (arrow).

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Ffg 29.-A, lateral view of left elbow shows joint effusion (arrows). No fracture was seen but patient was tender at the olecranon. 6, olecranon view shows olecra- non fracture (arrows). This demonstrates the importance of clinical correlation and special views in trauma radiography. (Both radiographs compliments of Dr. Anne C. Brower.)

Fig 30.-AP view of forearm on five-year-old boy who fell on his outstretched hand. Note fracture of radius (arrow) and marked curving of ulna indicating “bowing fracture.” (See J. Bone Joint Sufg. [Am.] 56-A:611, 1974.)

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Fig 31.-A, view of lateral forearm of 49-year-old woman who fell on curb was initially read as normal. Review revealed fluid in joint (arrow), and patient was reex- amined the following day. 9, fluoroscopy was performed: spot film shows fracture fragment from lateral epicondyle of humerus, displaced distally (arrow).

Fig 32.-Lateral wrist view of 11 -year-old child who had fallen on outstretched hand shows bowing of pronator fat pad (arrows). Fat pad of other wrist was normal. A Salter-Harris type I fracture was assumed. Soft tissues can be important second- ary signs of bony injury (see text).

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Fig 33.-A, lateral wrist view of 18-year-okf patlent involved in automobile dent interpreted as normal. Fracture of ulna was missed and patient was disch from emergency room. B, AP forearm on same patient three weeks later I healing fracture of ulna (amw) missed on previous views. Referred pain and clinical correlation are important in the adequate evaluation of the extremities.

acci- arged

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Fig M.-A, AP hand view of l&year-old patient involved in automobile accidant with “hand pain,” interpreted as normal. B, lateral view (not obtained the previous day) shows fracture of base of middle phalanx (arrow). Lateral views of the fingers are necessary to avoid subtle, but important, pathology.

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Fig 35.-Oblique view of left wrist of 20-year-old patlent with pain shows fracture of base of first proximal phalanx in right upper comer of film. This “comer” sign was missed on initial interpretation.

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Flg 36.-A, AP view of left first digit of 13-year-old patient who hurt thumb three weeks earlier shows no abnormality. The other two views were also normal. 8, “stress” view shows subluxation at metacarpophalangeal joint (gamekeeper’s thumb). Stress views after epiphyseal closure are often necessary to detect such an injury.

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Fig 37~Left,zkft thumb in 12-year-old chiid shows S&r-Harris type II fracture of proximal phalanx (arrow). Right, AP view of same finger with stress creates a more extensive fracture. Never obtain stress views in a child with unfused epiphyses (see Silverman F.N.: Problems in pediatric fractures. Semin. Roentgenol. 13:167, 1976).

not manifest a true AC separation. In fact, local injection of an- esthetic to the AC joint may be the only way to unmask such an injury.22

In the roentgen evaluation of the elbow and wrist, as with any other joint, we feel that at least four projections of each joint are necessary: AI’, lateral, and both obliques. If no definite bony fracture is seen, soft tissue changes such as effusions and dis- placement of the posterior fat gad in the elboW2’ and the prona- tor fat pad sign in the wrist may prompt one to look more closely for subtle pathology. In the elbow in children, a knowl- edge of the chronological appearance of the ossification centers is necessary to avoid m issing fractures.25

In the hand and fingers a lateral view is important and should be obtained in all patients with trauma to these areas (Figs 23- 37).

THE PELVIS AND LOWER EXTREMITY

The pelvis and lower extremity are commonly radiographed in trauma. The bright light can be an invaluable tool in evaluating radiographs of the pelvis, which often are quite dark. Remember to “bright light” all of the bony structures, especially the iliac

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Fig 38. -A, oblique view of pelvis of Pl-year-old runner who collapsed crossing the finish line was interpreted as normal (original film was very dark; print is mark- edly improved). B, close-up of same film showing avulsion fracture of the anterior superior iliac spine (arrow). Always remember to “bright light” periphery of dark pelvic films for pathology (see text).

wings and greater trochanters. Also look for soft tissue signs of hemorrhage or urinary extravasation, such as elevation of small bowel loops, abnormal bladder position, or displacement and ob- literation of fat planes in the pelvis.28 In fractures to the lower ischium and symphysis pubis, injury to the posterior urethra must be considered, as it occurs in approximately 10% of pa- tients. In this situation, a retrograde urethrogram must be per- formed before a catheter is inserted into the bladder. Only in this way can one avoid possibly creating a false tract from a ruptured urethra.2’

In evaluating the hips in trauma, it is best to obtain both AP and frog-leg views if possible. Subtle pathology not evident on one view may subsequently show up on the other. It is important to look for symmetry in evaluating subtle impacted fractures of the femoral neck, because these can be quite difficult to diag- nose. Tomography or nuclear scanning may be necessary to de- fine the exact pathology.

As with any other joint, at least four projections of the knee should be obtained. The lateral view should be done with a hor- izontal beam for detection of fat fluid levels, which may indicate bony pathology. A prominent joint effusion should also prompt one to look closely for fractures. In spite of this, patellar frac- tures may be very difficult to diagnose and may require special views (e.g., a skyline view) to detect subtle fractures.

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Fig 39.-A, AP pelvis of young woman with right hip pain interpreted as normal. B, frog-leg view in same patient demonstrates fracture of anterior inferior iliac spine to much better advantage (arrow).

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Fig 40.-A, AP pelvic view of lPyear-old boy with right knee pain. Both knees were normal, but pelvis shows left slipped capital femoral epiphysis and a question- able slippage on the right. B, frog-leg view of pelvis confirms bilateral slippage. Pain in lower femur and knee may be referred from hips.

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Fig 41.-A, AP view of left hip in 63- year-old patient involved in trauma. Film was originally very dark and read as normal, but the arrow points out an area of concern. B, repeat AP pelvis with better technique three weeks later shows same area (armw), still unclear for diagnosis. C, tomography shows intertrochanteric fracture of left hip and separation of left trochanter (arrow). This stresses the importance of tomography in this situation of continued pain with a subtle abnormality on plain films.

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Fig 42.-A, AP pefvlc vfew of 72-year-oki who fell and had left hip pain. It was inftfafly read as normal, but note sclerosis of left femoral neck. Arrow points to im- pacted fracture of left femoral neck. B, attempted frog-leg vfew of left hip shows small line of sclerosis indicating fracture (arrows). Impacted fractures are often missed and may be very difficult to diagnose unless special projections, tomography, or nuclear scanning are used in questionable cases (see text).

Fig 48.-AP pelvic view of retrograde urethrogram in 89- year-old patient with pelvic trauma. Fractures of right acetabulum and right inferior ramus are seen. Note extensive extravasation of contrast, which indicates posterior urethral rupture (see text).

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Fig 44.-A, horizontal beam lateral film of knee of l&year-old patient with knee trauma shows massive joint effusion with fat-fluid level (arrow). No fracture was demonstrated on plain films. B, tomography of knee shows small, nondisplaced fracture of proximal tibia (arrow). Soft tissue changes may reflect fracture, particu- larly in the younger age group (see text).

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Fig 45.-Oblique view of left knee in 52-year-old patient with injury shows fracture of patella (arrow). Even in retrospect, this was not seen on other plain films. Patellar fractures may be very difficult to diagnose, and special views in addition to plain films may often be required. Of course, a high clinical suspicion of this specific injury is helpful.

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Fig 46.-AP view of lower leg in five-year-old child with obvious fracture of mid- shaft of tibia. One should not, however, overlook associated bowing fracture of fibula (see text).

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Fig 47.-AP views taken one month apart of proxlmal lower leg in 15-year-old runner with pain. First view shows no abnormality, yet repeat shows healing of stress fracture. In the correct clinical situation, stress fractures should be suspected. Plain films are often normal and a nuclear scan may be required to exclude the diagnosis (see Daffner R.H.: Stress fractures: Current concepts. Skeletal Radio/. 2:221, 1978).

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Fig 48.-AP view of lower leg of 2Pyear-old man injured in soccer match. Ob- vious fracture of fibuia was seen, yet widening of ankle mortise was not appreciated until films were reviewed. Another example of “corner” pathology, which must ai- ways be looked for meticulously.

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Fig 49.- Lateral view of ankle in n-year-old patient with inversion injury. Fracture of base of fifth metatarsal is present (arrow). Always include base of fifth metatarsal on routine ankle views, as it is commonly avulsed in inversion injury. There can be a separate ossification center here. Clinical correlation and reference to Keats’ At/as of Normal Roentgen Variants may be helpful in difficult cases.

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Flg 60.-A, AP right foot view of lbyear-old with inversion injury is normal. B, oblique view of right ankle is the only view that showed fracture of base of fifth metatarsal (arrow). Some injuries emerge during manipulation for other views. Al- ways look at all the information on the film in all cases.

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flg 51 .-A, lateral ankle view of 17-year-old boy with injury playing soccer. Large joint effusion (enows) and marked soft tissue swelling were present. No fracture was seen. Patient was casted. 6, repeat AP ankle (out-of-cast) view six weeks later shows healing fracture (arrow), probably of Salter-Harris iii type. Soft tissue changes such as effusions, especially in children, very often indicate serious injury.

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Fig 52.-AP foot vfew of three-year-ofd who stubbed left toes shows Salter-Harris II fracture of base of first proximal phalanx. In questionable cases, obtaining the other side for comparison may be helpful lf symptoms warrant this procedure.

Fig 52.-A, lateral ankle view on go-year-old patient who fell down steps and had severe pain. No fracture was seen. 8, lateral tomography shows fracture of talus (arrow). This unusual fracture may be difficult to see and tomography is often indicated.

Fig 54.- Lateral ankle view in 20-year-old involved in automobile accident was originally read as normal. Fracture of calcaneus (arrow) was overlooked. The “cor- ners” hold the key in many instances. Remember to use all the information the x- ray gives you.

An effusion in the ankle can also indicate subtle bony pathol- ogy or simply reflect severe ligamentous sprain in the adult. Al- ways look at the base of the fif%h metatarsal for avulsion injuries related to the insertion of the peroneus brevis tendon. In the child with open epiphyses, an ankle effusion should be consid- ered evidence of epiphyseal fracture or dislocation until proved otherwise. In such cases, radiographs of the opposite joint for comparison or follow-up views in ten days may be required to define the exact injury.

Fractures of the foot usually present no particular diagnostic challenge, but in cases of “fracture versus accessory ossicle” in the adult and in possible Salter-Harris type I fractures in the child, views of the other side for comparison may be rewarding. As in the hand, the lateral view may also show pathology un- suspected on the AP or oblique views in the toes (Figs 38-54).

ACKNOWLEDGMENTS

We appreciate the always excellent technical assistance of Pat West, Shirley Yowell, and Rose Powell in the preparation of this manuscript, and the opportunity that the editor, Dr. Theodore E. Keats, gave us to voice our views.

REFERENCES

1. Claims Analysis. Malpractice Digest 2:1, 1980. 2. Nelson S.W.: Some important diagnostic and technical fundamentals in the

radiology of trauma with particular emphasis on skeletal trauma. Radial. Clin. North Am. 4:241, 1966.

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