Extremity Injuries Principle #3 & #4: X-ray & Safe Disposition

by Julianna Jung, MD, FACEP

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    00:01 And this brings us to principle number three.

    00:03 We should never ever, ever be fooled into a false sense of security by x-rays.

    00:10 So all tests are imperfect and x-rays are no exception.

    00:13 If you strongly suspect that a patient has a fracture, you should treat them as though they have a fracture rather than assuming that the x-ray is the beacon of truth.

    00:24 So in this case, we wanna be concerned about a fracture of one of the carpal bones and missed fractures like we said before are sources of morbidity and common causes of malpractice litigations.

    00:36 So we wanna be really meticulous in addressing any suspected fractures even if they’re not picked up on our initial x-rays.

    00:43 So the fracture that we suspect in this particular patient based on the area where she’s tender on exam is a scaphoid fracture.

    00:52 The scaphoid is the most commonly fractured carpal bone and x-rays actually have very poor sensitivity for scaphoid fractures.

    01:00 It’s a very common one that regular x-rays will miss.

    01:03 So the diagnosis should always be clinical.

    01:06 If the patient has an appropriate mechanism which ours does, she fell onto an outstretched hand which is certainly gonna raise the possibility of wrist fracture and she has tenderness in the area that’s known as the anatomic snuffbox.

    01:20 So that region again that was outlined on the prior slide.

    01:24 This is a situation where we should have a suspicion for scaphoid fracture regardless of the fact that the x-ray is negative.

    01:31 And it’s really, really important that we immobilize this patient because if we don’t, there’s actually a high risk of avascular necrosis or nonunion which can lead to all kinds of chronic problems down the line.

    01:42 So we definitely wanna make sure that we manage this patient as though a fracture is present even if we don’t see one on x-ray.

    01:50 Now, just as an aside, this particular x-ray actually does show a scaphoid fracture which is denoted by the arrow, but this is the exception rather than the rule.

    01:58 So even if your x-ray’s negative, you should maintain a strong index of clinical suspicion.

    02:04 Alright, so what’s the treatment for our patient gonna be? Well, we were not fooled by that negative x-ray so we’re gonna put our patient in a thumb Spica splint which is gonna maintain immobilization of the scaphoid joint and hopefully, prevent any morbidity associated with that.

    02:23 We did consult orthopedics for the Maisonneuve fracture because again, these patients always require surgical fixation.

    02:29 They placed a long leg splint and have made arrangements for her to follow-up and schedule her surgery as an outpatient.

    02:37 They’ve left strict instructions for her to be non-weight-bearing.

    02:40 She cannot put any weight on this leg.

    02:42 Her pain is well controlled.

    02:45 So we’re thinking maybe she’s ready for discharge.

    02:48 What do you guys think? Well, this brings us to principle number four.

    02:53 Unfortunately, our patient is required to be non-weight bearing because of her Maisonneuve fracture.

    02:58 That means that she needs to be able to use crutches.

    03:01 Walkers are not sufficient to allow non-weight-bearing and patients who have wrist fractures aren’t terribly good at using crutches or walkers.

    03:11 So she has a scaphoid fracture that’s gonna make it impossible for her to keep her weight off of her leg unless she’s literally hopping around the house which is probably not a great idea for a 79-year-old.

    03:22 So bottom-line, is orthopedic injuries can often impair ambulation, they can impair daily activities, and we have to ensure that our patient can function safely at home prior to discharge.

    03:34 In some cases, patients need to be admitted to the hospital and placed in nursing facilities temporarily so that they are able to receive the care that they need and keep the weight off of their injured extremities.

    03:50 So fortunately for our patient, she does have a supportive family, she lives in a home that’s only on one floor, she doesn’t have to climb stairs, and we’re able to get her a wheelchair.

    04:01 So she is gonna follow-up in three days with orthopedics and she seems pretty safe for discharge home.

    04:08 However, 24 hours after her discharge, she’s back in the Emergency Department, and now, she’s complaining of severe pain in the right leg.

    04:17 She says it’s 10 times worse than her original injury.

    04:20 It really feels terrible and she’s not getting any relief with the pain medicine we prescribed for home use.

    04:25 She’s also complaining of numbness and tingling in her foot and as you recall, she was completely neurovascularly intact in the leg before, so this is a new finding.

    04:35 What are we worried about for this patient? On our physical exam, her lower leg is swollen and tense especially in the anterior aspect, she’s got reduced strength for toe and ankle extension, so she can’t dorsiflex her ankle normally.

    04:51 She’s got decreased sensation in the webspace between the first and second toes.

    04:56 She’s got pain on passive flexion of the toes but she does have intact pulses.

    05:03 So diagnosis?

    About the Lecture

    The lecture Extremity Injuries Principle #3 & #4: X-ray & Safe Disposition by Julianna Jung, MD, FACEP is from the course Trauma (Emergency Medicine). It contains the following chapters:

    • Principle #3
    • Principle #4

    Included Quiz Questions

    1. A negative finding of fracture in an x-ray study rules out the diagnosis.
    2. Missed fractures are associated with significant morbidity.
    3. If a fracture is suspected then management of fracture may be initiated.
    4. Missed fractures are a common source of malpractice litigation.
    5. Fractures in carpal bones may sometimes be missed.
    1. Scaphoid
    2. Lunate
    3. Pisiform
    4. Trapezoid
    5. Capitate

    Author of lecture Extremity Injuries Principle #3 & #4: X-ray & Safe Disposition

     Julianna Jung, MD, FACEP

    Julianna Jung, MD, FACEP

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