Volume 3, Case 4
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaiʻi John A. Burns School of Medicine
This is a 24-year old female who comes to the emergency department with a chief complaint of foot pain. She describes the location of the pain in the back part of her foot to the triage nurse. The triage nurse informs the emergency physician about the foot pain. Radiographs of the foot are ordered.
She returns from the imaging department with her foot radiographs.
View foot radiographs.
Two views of her foot are shown here. The anterior portion of the radiographs are not shown to conserve disk storage space. Do you see anything wrong with these radiographs? To avoid pitfalls, always look at the edges and corners of the films.
These views of the foot demonstrate fractures of the fibula and posterior tibia. These fractures would be more easily seen on proper views of the ankle, however, foot films were ordered instead. These fractures are difficult to see on the views obtained.
View focused magnified view of the fracture sites.
The black arrows point to the fracture sites in the fibula and tibia in the upper radiograph. The white arrow points to the fracture site in the fibula visible in the lower radiograph. Look at the original radiographs again above.
After the patient returned from the imaging department, her radiographs were reviewed and no fractures were noticed on the radiographs. However, after examining her foot, it was evident that she most likely had an injury of her ankle. She was sent back to the imaging department for radiographs of her ankle which demonstrated the tibia and fibula fractures noted above. In retrospect, these fractures were also noticed on her foot films.
Ordering radiographs from the triage room is a common practice in many emergency departments. This can reduce the waiting time for patients so that their diagnostic studies can be completed more efficiently. However, realize that the triage process focuses on prioritizing care rather than making a final diagnosis. The patient's chief complaint may at times be deceiving. As in this case it may lead one to order suboptimal radiographic views without an examination. When the patient returns with radiographs in hand, there may be a tendency to focus on the radiographs and not on the patient. By depending solely on radiographs and a triage assessment, one may miss the diagnosis. Realize that patients who are referred directly to the imaging department from triage must still be examined upon return to ascertain that the proper radiographic images were ordered. Additionally, the radiographic interpretation should always be correlated with the patient's clinical findings. Injuries at other body sites must also be evaluated clinically, for example, head trauma following an extremity injury.
Another error of omission that is commonly made is on the patient who arrives with a large splint applied to a deformed extremity (often applied by paramedics). The patient is usually in severe pain making an examination painful for the patient. Such patients are commonly sent for radiographs where the fracture diagnosis is made and an orthopedic surgeon is called. Before calling the orthopedic surgeon, one should ascertain that this is indeed a closed fracture. The splint must be carefully removed and the extremity must be inspected for any skin punctures or wounds. Occasionally, cotton or padding will stick to a wound, hiding it. All cotton and padding must also be removed to ascertain that the skin surface is intact.
Although this computer program is called Radiology Cases in Pediatric Emergency Medicine, this patient is clearly an adult. However, the same process is commonly employed for children and the same type of fracture can still be seen in children and teens. This case just happened to occur in a young adult, but it could very well have occurred in a child or teen as well.