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