CommonlyCommonly

MissedMissed

FracturesFractures

Gregory W.Gregory W. Hendey Hendey, MD, FACEP, MD, FACEP

Professor of Clinical EmergencyProfessor of Clinical Emergency

MedicineMedicine

UCSF FresnoUCSF Fresno

Objectives:Objectives:

!! To recognize the most commonly missedTo recognize the most commonly missed

fractures in the EDfractures in the ED

!! To identify situations that are High Risk forTo identify situations that are High Risk for

an occult fracturean occult fracture

!! To discuss the evidence-based approach toTo discuss the evidence-based approach to

evaluating patients for an occult fractureevaluating patients for an occult fracture

““OccultOccult”” Fracture? Fracture?

!! Not readily visible on plain radiographs,Not readily visible on plain radiographs,

using standard techniquesusing standard techniques

!! Clinically importantClinically important

!! Change in managementChange in management

!! Significant risk of complications if missedSignificant risk of complications if missed

Anatomy of a Lawsuit:Anatomy of a Lawsuit:

!! KachallaKachalla, , Annals of EMAnnals of EM, 2007:, 2007:

!! 122 ED malpractice claims, 4 insurers122 ED malpractice claims, 4 insurers

!! Most common Most common ““MissedMissed Dx Dx””

!!#1-Fracture#1-Fracture, #2-, #2-InfxnInfxn, #3-MI, #3-MI

!! Most common Errors:Most common Errors:

!!Failure to order right test (58%)Failure to order right test (58%)

!!RadiologicRadiologic study (61%): #1- study (61%): #1-XrayXray

!!Misinterpretation of test (37%)Misinterpretation of test (37%)

!!RadiologicRadiologic study (66%): #1- study (66%): #1-XrayXray

KachallaKachalla, , Annals of EMAnnals of EM (cont.) (cont.)

!! Factors contributing to MissedFactors contributing to Missed Dx Dx::

!! Most cases: Cognitive + Contributing factorMost cases: Cognitive + Contributing factor

!! Cognitive factors:Cognitive factors:

!! 96%-Judgment, Knowledge, Memory96%-Judgment, Knowledge, Memory

!! Contributing factors:Contributing factors:

!!SignoutsSignouts (24%), Inadequate supervision (30%), (24%), Inadequate supervision (30%),

Workload (23%)Workload (23%)

The Plan:The Plan:

!! 4 clinical scenarios to illustrate common,4 clinical scenarios to illustrate common,

occult fractures:occult fractures:

!! Ankle and FootAnkle and Foot

!! HipHip

!! ElbowElbow

!! WristWrist

THE THE ANKLEANKLE

AND AND FOOTFOOT

Case 1:Case 1:

!! Young maleYoung male

twisted his ankletwisted his ankle

““snowboardingsnowboarding””

Ankle sprain?Ankle sprain?

!! R.I.C.E.R.I.C.E.

!! Functional immobilizationFunctional immobilization

!! CrutchesCrutches

!! Weight-bearing as toleratedWeight-bearing as tolerated

!! Follow up examFollow up exam

!! LigamentousLigamentous injury injury

!! Persistent pain / effusionPersistent pain / effusion

!!Occult fracture???Occult fracture???

When should I consider CT/MRI?When should I consider CT/MRI?

1)1) Persistent pain/effusion at follow upPersistent pain/effusion at follow up

2)2) High clinical suspicionHigh clinical suspicion

!! Mechanism, examMechanism, exam

!! Important occultImportant occult fx fx of the ankle/foot: of the ankle/foot:

!! TalarTalar dome fracture dome fracture

!! TillauxTillaux fracture (lateral tibia) fracture (lateral tibia)

!! CalcaneusCalcaneus,, Navicular Navicular

!! Lateral process of TalusLateral process of Talus fx fx

HaapamakiHaapamaki, , Am JAm J Roentgenol Roentgenol,, 2004: 2004:

!! Retro, 344 pts withRetro, 344 pts with fx fx on Ankle/foot CT on Ankle/foot CT

!! Pts withPts with Fx Fx not visualized on plain films: not visualized on plain films:

!! CalcaneusCalcaneus (20) (20)

!! Talus (15)Talus (15)

!! TillauxTillaux (7) (7)

!! CalcaneusCalcaneus fracture fracture

!! Male : Female = 5:1Male : Female = 5:1

!! Associated injuriesAssociated injuries

!!L-spineL-spine

!! OperativeOperative vs vs Casting Casting

BohlerBohler’’ss angle angle

HarrisHarris Calcaneal Calcaneal view view

!! CT scan:CT scan:

!! DxDx occult injury occult injury

!! Plan surgeryPlan surgery

!! TalarTalar dome fracture dome fracture

!! OsteochondralOsteochondral lesion lesion

!! CT or MRICT or MRI

!! Non-wt bearingNon-wt bearing vs vs Arthroscopy Arthroscopy

!! TillauxTillaux fracture fracture

!! Lateral tibiaLateral tibia

!! Avulsion, ATFAvulsion, ATF lig lig

!! Adolescents, SH-IIIAdolescents, SH-III

!! SurgicalSurgical

Our patient:Our patient:

!! Lateral process ofLateral process of

the Talus fracturethe Talus fracture

!! ““uniqueunique”” to to

snowboardingsnowboarding

ValderrabanoValderrabano, , Am J Sports MedAm J Sports Med, 2005:, 2005:

!! Case series, 20 snowboardersCase series, 20 snowboarders

!! Lateral process talusLateral process talus fx fx

!! Mechanism: axial load,Mechanism: axial load, dorsiflexion dorsiflexion,,

external rotation,external rotation, eversion eversion

!! 2/3 treated surgically2/3 treated surgically

!! Good return of functionGood return of function

High Risk Tips:High Risk Tips:

!! CT helpful for:CT helpful for:

!! High suspicion (mechanism, exam)High suspicion (mechanism, exam)

!! Poor recoveryPoor recovery

!! High risk situations:High risk situations:

!! Fall from heightFall from height——CalcaneusCalcaneus

!! AdolescentAdolescent——TillauxTillaux

!! SnowboardingSnowboarding——Lateral process of TalusLateral process of Talus

THE THE HIPHIP

Case 2:Case 2:

!! 7575 yo yo F fell onto her L side F fell onto her L side

!! Pain in L hip with weight bearingPain in L hip with weight bearing

ShentonShenton’’ss Line Line Occult hip fractureOccult hip fracture

!! Common, and clinically importantCommon, and clinically important

!! Bone Scan (?)Bone Scan (?) vs vs CT CT vs vs MRI MRI

!! MRI is most supported by evidenceMRI is most supported by evidence

!!Older studies of Bone scanOlder studies of Bone scan vs vs MRI MRI

!! All three are superior to plain filmsAll three are superior to plain films

!! Local resources may dictate choiceLocal resources may dictate choice

MRIMRI

!! FrihagenFrihagen,, Acta OrthopActa Orthop, , 2005:2005:

!! 100 pts, hip trauma, negative plain films100 pts, hip trauma, negative plain films

!! All had MRIAll had MRI

!! 46 femoral neck or46 femoral neck or intertrochanteric fx intertrochanteric fx

!! 27 other fractures (mostly pelvic)27 other fractures (mostly pelvic)

!! 30 had surgery30 had surgery

MRIMRI vs vs CT: CT:

!! LubovskyLubovsky, Injury, 2005:, Injury, 2005:

!! 6 pts with suspected6 pts with suspected fx fx, negative, negative Xrays Xrays

!! All had MR and CT (slice?)All had MR and CT (slice?)

!! 5 of 6 had5 of 6 had fx fx. CT . CT ““misdxmisdx’’dd”” three. three.

•• GreaterGreater tuberosity fx tuberosity fx in 3 who had inter- in 3 who had inter-

trochanteric fxtrochanteric fx by MRI by MRI

MRI: MRI:

!! Can CT exclude hipCan CT exclude hip fx fx??

!! Better than plain filmsBetter than plain films

!! Rapid advances in technologyRapid advances in technology

!! As good as MRI?As good as MRI?

!! Future studies?Future studies?

High Risk tip:High Risk tip:

!! MRI is still more MRI is still more ““hiphip”” than plain films, than plain films,

bone scan, or CTbone scan, or CT

!! Question of MRIQuestion of MRI vs vs Newer generation CT Newer generation CT

remains unresolvedremains unresolved

THE THE ELBOWELBOW

Case 3:Case 3:

!! 3131 yo yo M crashed his bicycle M crashed his bicycle

!! c/o R elbow painc/o R elbow pain

!! No deformity, slightly swollenNo deformity, slightly swollen

!! Decreased ROMDecreased ROM

Occult elbow injury:Occult elbow injury:

!! AdultsAdults

!! Radial headRadial head fx fx

!! ChildrenChildren

!! SupracondylarSupracondylar distal distal humerus fx humerus fx

Approach to the Adult Elbow:Approach to the Adult Elbow:

!! 90 degree lateral90 degree lateral

1)1) Fat padsFat pads

•• Bulging anteriorBulging anterior

•• Any posteriorAny posterior

2)2) Radio- Radio-capitellarcapitellar line line

GiovanniGiovanni Monteggia Monteggia

!! Italian surgeonItalian surgeon

!! 1762-18151762-1815

!! Acquired syphilisAcquired syphilis

during an autopsyduring an autopsy

High Risk tips:High Risk tips:

!! Look for fat padsLook for fat pads

!! Draw the lineDraw the line

!! DonDon’’t get syphilis from an autopsy!t get syphilis from an autopsy!

Case 4:Case 4:

!! 3131 yo yo M struck by martial arts instructor M struck by martial arts instructor

!! c/o wrist painc/o wrist pain

!! Snuffbox tendernessSnuffbox tenderness

ScaphoidScaphoid fracture fracture

!! Most common carpal fractureMost common carpal fracture

!! 10-20% occult10-20% occult

!! Distal blood supplyDistal blood supply

!! ProximalProximal fx fx worse worse

!! Delayed complications:Delayed complications:

!! Non-unionNon-union

!! AvascularAvascular necrosis necrosis

AVN, non-unionAVN, non-union

Frequent occult fracturesFrequent occult fractures

++

Frequent complicationsFrequent complications

==

ThumbThumb spica spica splint and follow-up splint and follow-up

Best way to find occultBest way to find occult fx fx??

!! Bone scan:Bone scan:

!! Traditional, tried and trueTraditional, tried and true

!! MRI:MRI:

!! Better than bone scan in multiple studiesBetter than bone scan in multiple studies

!! CT:CT:

!! New technology, as good as MRI?New technology, as good as MRI?

!! U/S:U/S:

!! Really?Really?

Bone Scan:Bone Scan:

!! Murphy, Murphy, JJ Emerg Emerg Med, Med, 1994: 1994:

!! 54 pts, snuffbox tenderness,54 pts, snuffbox tenderness, neg xray neg xray

!! ThumbThumb spica spica, re-exam, films in 2 wks:, re-exam, films in 2 wks:

•• 37 had no pain, negative films37 had no pain, negative films

•• 2 had2 had scaphoid fx scaphoid fx on films on films

•• 15 had pain,15 had pain, neg neg films--- films---Bone scan:Bone scan:

!! 6 positive for6 positive for scaphoid fx scaphoid fx

Bone scanBone scan vs vs CT: CT:

!! Groves, Groves, AJRAJR, 2005:, 2005:

!! 51 pts with51 pts with neg neg X-rays X-rays

!! 16 slice CT16 slice CT vs vs Bone scan at 2 wks Bone scan at 2 wks

!! CT positive in 14, Bone scan in 23CT positive in 14, Bone scan in 23

!! True fractures? Gold standard?True fractures? Gold standard?

MRI:MRI:

!! BrydieBrydie, , British Journal of RadiologyBritish Journal of Radiology, 2003:, 2003:

!! 195 pts, snuffbox tenderness,195 pts, snuffbox tenderness, neg neg films films

!! All had MRI w/in 2 wks (most w/in 3d)All had MRI w/in 2 wks (most w/in 3d)

!! 37 (19%) had37 (19%) had scaphoid fx scaphoid fx

!! 37 (19%) had another37 (19%) had another fx fx detected detected

!! RecRec early MRI, forget splint if Negative early MRI, forget splint if Negative

MRIMRI vs vs CT: CT:

!! MemarsadeghiMemarsadeghi, , Radio logyRadio logy, 2006:, 2006:

!! 29 pts,29 pts, neg neg X-ray, had CT (4) and MRI X-ray, had CT (4) and MRI

!! Gold std: plain films at 6 wksGold std: plain films at 6 wks

!! 1111 scaphoid fx scaphoid fx

!! MR found 100%, CT found 8/11 (73%)MR found 100%, CT found 8/11 (73%)

!! CT better at corticalCT better at cortical fx fx

!! MR better atMR better at trabecular fx trabecular fx

Newer info on CT:Newer info on CT:

!! TyTy et al., et al., HandHand, 2008, 2008

!! 28 pts with snuffbox tenderness,28 pts with snuffbox tenderness, neg Xray neg Xray

!! CT (slice?):CT (slice?):

!!44 scaphoid fx scaphoid fx, 10 others (radius, carpals), 10 others (radius, carpals)

!!14 patients CT negative14 patients CT negative

!! Gold std:Gold std: neg neg films at 6 wk f/u films at 6 wk f/u

!! 8/14 lost to f/u8/14 lost to f/u

!! No missedNo missed fx fx (?) (?)

CT:CT:

!! Cruickshank,Cruickshank, Emerg Emerg Med Aus, 2007: Med Aus, 2007:

!! 47 pts, snuffbox tenderness,47 pts, snuffbox tenderness, neg Xrays neg Xrays

!! CT (64 slice): 7CT (64 slice): 7 scaphoid fx scaphoid fx, 10 others, 10 others

!! 30 patients CT negative:30 patients CT negative:

!! Gold std: 2 wk f/u,Gold std: 2 wk f/u, Xrays Xrays, MRI, MRI prn prn (8) (8)

!! MRI found one moreMRI found one more fx fx ( (capitatecapitate))

Remaining questions:Remaining questions:

!! Is newer CT as good as MRI?Is newer CT as good as MRI?

!! Is it important to findIs it important to find trabecular Fx trabecular Fx??

!! Do occultDo occult fx fx have same complication rate? have same complication rate?

!! Should I order MR or CT today instead ofShould I order MR or CT today instead of

splint and follow-up next week?splint and follow-up next week?

High Risk tip:High Risk tip:

!! DonDon’’t ignore thet ignore the scaphoid scaphoid::

!! Splint and follow-up, orSplint and follow-up, or

!! Advanced imaging (MRAdvanced imaging (MR vs vs CT) CT)

Summary:Summary:

!! Plain film and physical findings that suggestPlain film and physical findings that suggest

an occult fracturean occult fracture

!! Evidence-based approach to evaluatingEvidence-based approach to evaluating

patients for an occult fracturepatients for an occult fracture

!! 4 common, important clinical scenarios4 common, important clinical scenarios