Volume 4, Case 14
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaiʻi John A. Burns School of Medicine
This is a 10-year old male who fell down three stairs yesterday afternoon. He now presents to the emergency department (20 hours later) complaining of persistent pain in his right wrist and left foot. He denies head trauma or symptoms of head injury.
Exam VS T37.2 (tympanic), P80, R20, BP 125/65. There is point tenderness over the distal radius. There is slight swelling in this area but no deformity. There is no scaphoid tenderness. Neurovascular testing distally is intact. There is diffuse tenderness over the dorsal lateral portion of his left foot. There is no swelling evident. He bears weight well on both feet.
Radiographs of his right wrist and left foot are obtained. The wrist films demonstrate a non-displaced distal radius torus fracture. A volar splint is placed. Orthopedic follow-up is arranged.
View left foot radiographs.
Examine these radiographs for any abnormalities.
What type of imaging study would you order at this point? 1) Nuclear bone scan, 2) CT scan, 3) Clinical follow-up without further imaging studies.
The paragraph above is merely a distraction. It attempts to lull you into believing that these radiographs are normal. However, these radiographs would not be displayed here if they are normal. You are fortunate since you now know that these radiographs are somehow abnormal. Unfortunately in the emergency department, we are not afforded this luxury. While we try to examine all radiographs carefully, the degree of scrutiny that we apply to a radiograph is proportional to our degree of clinical suspicion of an abnormality. In this case, the suspicion of a foot fracture is low since his tenderness is not focal, there is no swelling, he presents on the day after the injury, and he can bear weight well on the foot. All of these clinical factors suggest that the likelihood of fracture is low.
Unfortunately, it is these low risk cases that tend to have small fractures that are the most difficult to identify. They demand maximal scrutiny in order to find them. Cases in which we expect to find a fracture, are usually more obvious radiographically. Thus, the cases with the most difficult fractures to identify on radiographs, are usually the radiographs which we examine with the least scrutiny.
Fortunately, most orthopedic abnormalities missed on the initial interpretation of radiographs are small (that's why they are missed) and not of major clinical consequence. These small injuries can usually be treated at follow-up. When fractures are not identified during the initial emergency department visit, patients are usually dissatisfied with their emergency care since the patient expected to find a fracture (that's why they came to the E.D. in the first place), and the physician failed to find it. These missed fractures often result in complaints. Such complaints can usually be prevented if you inform the patient during the initial E.D. visit that a radiologist, reading the radiographs later, may have a different interpretation of the radiographs. If an occult fracture is suspected despite negative radiographs, it may be prudent to splint the injury pending clinical follow-up and a second opinion from a radiologist.
You have one more chance to scrutinize our patient's foot radiographs to identify any abnormalities.
These radiographs show non-displaced fractures of the distal second, third, and fourth metatarsals. The second and third metatarsals fractures involve the metaphysis. The third metatarsal fracture is a Salter-Harris type II fracture involving the metaphysis extending into the physis (growth plate). The fourth metatarsal fracture involves the epiphysis. Note that it extends from the epiphysis into the physis and possibly into the metaphysis. This is a Salter-Harris type III or type IV fracture. Point tenderness was not appreciated on examination since more than one fracture is present in the foot. Refer to Case 18 of Volume 1, Salter-Harris, for more discussion on the Salter-Harris classification of fractures involving the growth plate.
View a focused view of these areas.
The upper image is taken from the AP view and the lower image is taken from the oblique view.
The fractures are pointed out below.
The black arrows point out the metaphyseal fractures of the second and third metatarsals. The third metatarsal fracture is evident. The second metatarsal fracture is not obvious, but the angle of the metaphysis where the arrow is pointing, is sharper than it should be.
The white outlined arrow points out the lateral epiphyseal fracture of the fourth metatarsal. The lucency on the medial side of the fourth metatarsal epiphysis is also a fracture (no arrow).
If you failed to identify all the fractures in his foot, your patient may be less than satisfied even though splinting the foot would be an appropriate initial management for the fractures. One suggestion as pointed out in Case 19 of Volume 1 is to routinely discharge all patients with a form such as that below if radiographs are ordered:
1. The emergency physician has read your X-ray as: Normal foot (example)
2. Large abnormalities requiring urgent care are generally obvious and, therefore, this is unlikely at this point. An emergency physician can find most of the problems on an X-ray, but the emergency physician is not a specialist in radiology.
3. To be sure, we will have the hospital radiologist (X-ray specialist) read your X-ray on the morning of the next working day (Monday through Saturday). If there is an important difference in the X-ray reading, we will try to call you or your doctor, but this doesn't always happen. To double check us, please call your physician or the hospital clinic (999-9999) to find out how your X-ray is being read by the radiologist. If you call the hospital X-ray department directly, they will not give you the reading over the phone since the medical reading is not understood by most people. It must be done through your doctor.
4. When you call your doctor or your doctor's office nurse, tell him/her that you came to the Emergency Department where some X-rays were taken, and you were told to call your doctor to double-check the X-ray reading with the hospital radiologist. The most common things that are missed on X-ray readings are tiny fractures (cracks, chips, or hairlines) and small areas of infection (bronchitis, pneumonia, bone infection, etc.).
5. To be sure that these problems are not there, it is important that you contact your physician so that you will receive the proper care for this condition.
6. For injuries, pain that lasts for more than a week or pain that doesn't get better after two days, could mean that you have a hidden broken bone, even if your X-rays are normal (X-rays cannot find all broken bones). See your doctor for an examination of the area. Another set of X-rays may be needed.