Missed fractures in Emergency Department
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Transcript of Missed fractures in Emergency Department
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 H
D islocations
O ccult fracture
H alf of injuries missed
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
SCAPHOLUNATE DISSOCIATION
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-D
PERILUNATE DISLOCATION
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-O
SCAPHOID FRACTURE
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
WRIST-H
GALEAZZI FRACTURE
WRIST-H
DISTAL RADIUS FX + CARPAL INJURY
ELBOW anatomy
Radiocapitellate line: AP & Lat Anterior humeral line : Lat view Fat pads
ELBOW - D
RADIAL HEAD DISLOCATION When identified, must look for a proximal
ulnar fracture (see “Monteggia Fracture”)
ELBOW - O
RADIAL HEAD FRACTURE
ELBOW - H
MONTEGGIA FRACTURE IN CHILDREN
HIP- D
D – Hip dislocation ( Ant & Post )
HIP- O
O – Femoral Head Fracture ?? CT
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.
KNEE - H
MAISONNEUVE FRACTURE
FOOT - ANATOMY
FOOT - ANATOMY
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 –D
LISFRANC INJURY COMPARTMENT SYNDROME
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%
Painful Knee
Septic Inflammatory OA Soft tissue ( ACL, MM, LM, MCL, LCL) -----
MRI AVN ( SONK, Secondary Osteonecrosis) Patella Dislocation Post TKR Fracture
Questions