Suspicion Of Fracture Research Articles

Lisfranc Injury - Gymnastics

HISTORY: The patient was a 17-year-old ASG level 10 female gymnast who was performing a power tumbling pass on the floor exercise when she felt a crack in her left foot upon landing. She was unable to weight-bear and had to withdraw from the competition. PHYSICAL EXAMINATION: The patient presented to our office the two days later with mild swelling of the foot, but she could not bear weight without pain. She had no foot deformities with a normal arch. The patient was neurologically intact to light touch and motor strength in both lower extremities. She had a positive squeeze test. She was maximally tender to palpation at the first and second TMT joints. Rotation of the midfoot caused her the most pain, but her tibiotalar and subtalar joints were pain free and mobile without pain. DIFFERENTIAL DIAGNOSIS: 1. Left foot ligament sprain 2. Left midfoot fracture 3. Bone contusion TEST AND RESULTS: XR non-weight-bearing AP and lateral: no definite abnormal finding XR weight-bearing AP and lateral: no definite abnormal finding MRI w/o IV contrast: Lisfranc ligament: surrounding edema with partial tears, suspicion for fracture - midfoot CT w/o IV contrast: minimally displaced avulsion fracture of the plantar base of the second metatarsal FINAL/WORKING DIAGNOSIS: Midfoot Lisfranc joint ligament tears with avulsion fracture at the second metatarsal TREATMENT AND OUTCOMES: 1. Non-weightbearing boot for 4 weeks with crutches 2. Partial weightbearing boot for 4 weeks followed with organized PT for 3 months 3. Due to COVID, physical therapy performed mostly at home 4. Resumed gymnastics 32 weeks post-injury full time with no sequelae; accepted scholarship from the Ohio State University gymnastics team

Could Ultrasound Be Used as a Triage Tool in Diagnosing Fractures in Children? A Literature Review.

Fracture is one of the most frequent causes of emergency department visits in children, conventional radiography being the standard imaging tool used for following procedures and treatment. This imagistic method is irradiating and harmful, especially for children due to their high cell division rate. For this reason, we searched the literature to see if musculoskeletal ultrasound is a good alternative for diagnostic and follow-up regarding fractures in the pediatric population. After searching the databases using MeSH terms and manual filters, 24 articles that compare X-ray and ultrasound regarding their specificity and sensitivity in diagnosing fractures were included in this study. In the majority of the studied articles, the specificity and sensitivity of ultrasound are around 90–100%, and with high PPVs (positive predictive values) and NPVs (negative predictive values). Although it cannot replace conventional radiography, it is a great complementary tool in fracture diagnosis, having a sensitivity of nearly 100% when combined with clinical suspicion of fracture, compared with X-ray.

1301 Early MRI in the Diagnosis of Suspected Scaphoid Fractures – An Audit of a Redesigned Diagnostic Pathway

Abstract Introduction MRI is the gold standard for investigation of suspected scaphoid fractures, which can be missed on initial x-rays. This full cycle audit reports the impact of our new patient pathway, which changes repeat x-rays at 2 weeks to urgent limited sequence scaphoid MRI for those with normal initial x-rays, but clinical suspicion of fracture at initial clinic visit. Method A second cycle audited MRI requests for suspected scaphoid fractures at Southmead hospital following implementation of the new pathway in October 2020. We collected wait times from request to scan, and radiologist reports. Results were compared to our first cycle, 6-month time period. Results he results for 24 limited sequence MRIs via our new pathway were compared to 134 full wrist MRIs of the first cycle. Two scans (9.1%) were positive for scaphoid fracture versus 12% in the first cycle. 19 scans (86%) identified alternate pathology including sprain (6), bone bruise (5), non-scaphoid fractures (4) and degenerative change (3). 1 scan (4.5%) was reported as normal. 73% of MRIs were performed within 14 days, compared to 63% in previous cohort. Conclusions Our new pathway using limited sequence MRI identified similar rates of scaphoid fractures. Reduced time to MRI was observed compared to the previous cohort due to shorter scan durations and resulted in earlier diagnosis and fewer outpatient follow-up appointments. Our new pathway has benefits to patient experience and also reduces footfall in hospital, during a time of global Covid-19 pandemic, with no increase in costs.

A case of an injured calcaneus secundarius in a professional soccer player

BackgroundThe calcaneus secundarius (CS) is an accessory ossicle of the anterior facet of the calcaneus and is usually asymptomatic. This accessory bone can be frequently mistaken for a fracture of the anterior process of the calcaneus. Few reports of symptomatic CS have been published, and physicians need to be familiar with imaging strategies when encountering chronic ankle pain or in case of suspicion of fracture of the anterior process of the calcaneus.Case presentationWe describe the case of symptomatic CS in a professional soccer player injured during a match. First, computed tomography showed a large CS. Second, magnetic resonance imaging (MRI) demonstrated synchondrosis between the CS and the calcaneus, as well as edema (high MR T2 signal) within it, corresponding to posttraumatic edema. The patient was successfully treated with nonsteroidal anti-inflammatory drugs and physiotherapy; no surgical management was necessary. At the 4-week follow-up, he was pain-free and returned to activity.ConclusionThis case illustrates the role of imaging for the diagnosis of CS in cases of acute pain of the foot. CT, as well as MRI, helped to confirm the diagnosis of CS traumatized synchondrosis, which can be mistaken for a fracture.

Evaluation of Patients with Suspected Hip Fracture but Negative X-Ray Findings

In patients with hip fracture, initial radiographs occasionally are negative. When the suspicion for fracture remains high despite negative x-ray

The Role of Pain Scoring in Multi-detector Computed Tomography Indications in Pediatric Occult Fractures

Introduction: Computed tomography (CT) is used in emergency orthopedic trauma cases with suspicion of fracture that cannot be detected on X-ray. Also pain during examination in patients with fracture is important for clinicians. We aimed to investigate whether pain severity is indicative of multi-detector CT (MDCT). Methods: A total of 175 patients included in the study. Visual analogue scale (VAS) was used to evaluate pre-examination pain in all patients. The most painful and suitable region for palpation were determined, palpated and the patients were asked to re-score their pain. In this way, the local VAS score was determined. MDCT was performed in all patients with general VAS of > 5. MDCT results were compared with the VAS scores. Results: Fracture detection in MDCT was 61.1% in patients with general VAS score of ≥ 5. Of the 105 patients with the local VAS score of ≥ 7, 90 had fractures. In these patients, the sensitivity, specificity, positive predictive value and negative predictive value of MDCT for detecting fractures were 84.1%, 77.9%, 85.7% and 75.7%, respectively. Conclusion: We believe that MDCT should be performed for suspected fracture if pain severity is high in isolated extremity trauma cases without fracture detection on X-ray.

Single-shot CT after wrist trauma: impact on detection accuracy and treatment of fractures

ObjectiveTo evaluate accuracy of fracture detection and therapeutic impact of a single-shot CT protocol as a primary imaging tool in all patients with clinical suspicion of wrist injury, and evaluate the resulting impact on therapy.Materials and methodsWe performed a single-institution study on all patients with suspicion of fractures of the wrist and carpus. All patients underwent conventional radiography, thereafter single-shot wrist CT, and then 1-year follow-up. Physicians and radiologists prospectively scored likelihood of fracture presence on a five-point scale before and after CT. Three surgeons proposed a treatment regimen (functional, cast, reduction, or operative) based on clinical and radiological data, first with knowledge of conventional radiography, and then with knowledge of CT. The reference standard for fracture presence was based on all data. We performed receiver operating characteristic (ROC) analyses and calculated proportion of wrists with treatment changes due to CT imaging.ResultsNinety-eight patients participated (63% female, mean age 53, range, 18–87 years old) with 100 wrist CTs. Conventional radiography detected true-positive fractures in 45, and CT in 61 wrists. The areas under the curve for fracture detection were 0.85 (95% CI 0.77–0.93) for conventional radiography and 0.97 (95% CI 0.93–1.00) for CT. Treatment changed in 24 (24%, 95% CI 16–33%) - 31 (31%, 95% CI 23–41%) wrists, mostly involving a decrease in the rate of cast immobilization.ConclusionsSingle-shot CT in patients with clinical suspicion of wrist injury increases accuracy of fracture detection. This has a significant impact therapy in this population, mainly on cast immobilization.Trial RegistrationWe registered the study at www.clinicaltrials.gov, NL43482.091.13.

HOW SCAPHOID FRACTURES ARE TREATED IN BRAZIL.

ABSTRACTObjectiveTo verify how hand surgeons manage scaphoid fractures and their complications.MethodsTwo hundred questionnaires were distributed during the 36th Brazilian Hand Surgery Congress (2016).ResultsOn suspicion of fracture without radiographic confirmation, 57% of surgeons request a CT or MRI scan, while 43% opt for immobilization and consecutive radiographs. In stable fractures the preference was for treatment with plaster cast. In fractures with no scaphoid waist displacement, 33% opt for percutaneous fixation. In displaced waist or proximal pole fractures, 66% and 99.4%, respectively, opted for surgical treatment. Most surgeons treat waist nonunion with a nonvascularized bone graft. When absorption at the site of nonunion is greater than 4 mm, 50% prefer to use iliac graft and screw fixation. In proximal pole nonunion, the Zaidemberg technique is preferred by 64%. More experienced surgeons are more likely to request tests in occult fractures (63.9% versus 47.6%; p=0.04), and tend to recommend surgery for distal third fractures more frequently (16.4% versus 4.7%; p=0.02).ConclusionsWe have provided an overview of treatment preferences for scaphoid fractures. It should be noted that more experienced surgeons are more likely to request additional tests for occult fractures and to recommend surgical treatment of distal third fractures. Level of Evidence IV, Cross-sectional survey.

Ankylosing spondylitis and spinal trauma – with an emphasis on the role of radiology

Diagnosis of spinal injury in a patient with chronic ankylosing spondylitis can be challenging. Minor insult can result in an unstable three-column injury which may be subtle. Spinal deformity, osteoporosis and limited mobility are associated with difficulty in positioning patients for imaging studies, including radiography and both computed tomography and magnetic resonance imaging. It is important to maintain a high index of suspicion of fracture, avoid forced neck extension during radiological imaging, and to consider whole spine imaging in these patients. Other causes of neurological symptoms simulating potential spinal injury are also briefly addressed.

Emergency physicians performed Point-of-Care-Ultrasonography for detecting distal forearm fracture

ObjectivesSeveral studies focusing diagnosis of forearm fracture using Point-of-Care-Ultrasonography (POCUS) had been carried out in children. There is a lack of evidence for the utility of sonographic (US) examination for detecting of distal forearm fracture in adults. We aim to determine the diagnostic sensitivity and specificity of POCUS examination for the fracture of the distal radius and ulna in adult patients presenting with blunt forearm trauma. Material and MethodsAdult patients presenting with acute distal forearm trauma and suspicion of fracture were enrolled into study. POCUS had been performed by blinded emergency physicians, than anteroposterior and lateral x-rays was obtained. If inconsistency between x-rays and POCUS has been occurred, computed tomography were ordered. Assessment of orthopedic surgeon was accepted as a gold standard diagnosis. ResultsNinety three POCUS were performed in 90 patients. Fifty nine radius and 19 ulna fracture had been diagnosed. POCUS detected all radius fracture, but missed 2 ulna fracture. There were 4 false positive results for both radius and ulna with POCUS. X-ray missed 4 radius, and 1 ulna fractures. Diagnostic sensitivity and specificity of POCUS for fracture of ulna were 89.5% (CI%95, 65.5–98.1) and 94.6 (CI%95, 86–98.2), for fracture of radius were 100% (CI%95, 92.4–100), and 88.2%. (CI%95, 71.6–96.1). ConclusionEmergency physician performed POCUS examination is very sensitive and specific the diagnosis of distal forearm fracture. Diagnostic sensitivity of POCUS for radius fracture is higher than x-ray.

G96(P) Optimising facial imaging for trauma in a paediatric emergency department (ed)

Aims In the context of trauma, plain facial X-rays do not represent the gold standard imaging modality, as many patients with equivocal findings will require further imaging with facial CT views. The aim of this project was to review the use of facial X-rays of patients seen in a paediatric ED following trauma, to ascertain the degree of correlation between clinical signs and radiological findings. Methods Retrospective review. All facial X-rays performed within the ED over a 1 year period (09/2012–09/2013) were identified from the hospital PACS system. Clinical details were obtained from the ED notes and compared with the X-ray report from a consultant radiologist. Results See Figure 1 below. Conclusions The vast majority of facial X-rays performed in our ED showed no evidence of fracture. A negative X-ray may be falsely reassuring as, in some cases, clinical suspicion of bony injury was high, but no further investigation/referral was made. In other cases, a facial CT was performed despite a negative facial X-ray. Therefore, in general, facial X-rays and their interpretation by ED clinicians do not appear to make a significant difference to the subsequent clinical management of patients. If suspicion of fracture is high then CT would be a better imaging modality, as where suspicion remains high an equivocal plain X-ray result would not confidently exclude facial bone fracture. On the basis of this we have developed a new clinical guideline which stratifies patients into 3 management paths according to clinical signs and symptoms: Our intention is to reduce the number of unnecessary facial X-rays, and practice will be re-audited one year post- implementation.

Identification of Lipohemarthrosis With Point-of-Care Emergency Ultrasonography: Case Report and Brief Literature Review

BackgroundTraumatic knee pain is a common complaint in the emergency department (ED). Conventional radiographs are often ordered as the initial screening study, but might not be readily available or always identify significant fractures. Ultrasonography has been shown to be useful in the evaluation of knee fractures not identified by radiography. ObjectivesTo discuss and briefly review the literature regarding the use of suprapatellar bursal ultrasonography to detect lipohemarthrosis (LH) as a surrogate marker for an intraarticular knee fracture. Case ReportA 37-year-old man presented to the ED after a traumatic knee injury. Bedside ultrasonography demonstrated the characteristic triple layer sign of LH, raising the suspicion for an intraarticular fracture. The diagnosis was later confirmed with radiography and computed tomography (CT). ConclusionsThe sonographic finding of LH may be used as a sensitive surrogate marker for intraarticular knee fracture in the ED. Ultrasound can be considered as an adjunct modality in ED patients with suspicion for fracture and negative knee radiographs.

Treatment of pathological humeral shaft fractures with intramedullary nailing. A retrospective study

A consecutive series of 22 pathological fractures of the humeral shaft in 21 patients treated at one institution were included in this retrospective study. Patients were treated with anterograde locked intramedullary nailing. Mean follow-up was 22.7 months (range 3-60). Mean VAS score improved from 89.5 (range 80-100) to 14.5 (range 0-40). In most patients there was a satisfactory return to daily activities within six weeks of surgery. Seventeen of 19 patients reported to be satisfied. Mean duration of hospitalization after surgery was 4.3 days (range 2-15). There were no complications related to the implants. There were no operative complications and the average operation time was 48 minutes (range 35-160). The consolidation rate was 80%. We emphasize that suspicion of fracture and interdisciplinary work between oncologists and orthopaedic surgeons are of crucial importance for survival time and individual treatment.

Geriatric Literature Review: Revisited

Geriatric Literature Review: Revisited

MRI diagnosis of occult hip fractures

Background Most fractures of the proximal femur are easily diagnosed by conventional radiography. When the images are judged to be negative or equivocal and a clinical suspicion of fracture persists, another approach is to use magnetic resonance imaging (MRI) to help reach a diagnosis.Methods In a prospective study running from November 1998 to December 2001, we registered all patients being examined by MRI who had had a negative or equivocal radiograph and where there was continued clinical suspicion of hip fracture.Results 100 consecutive patients (67 women) were included, with an average age of 80 (37–100) years. The MRI examinations corresponded to 4% of the 2,350 patients admitted with hip trauma during the study period. 46 patients had a femoral neck or intertrochanteric fracture on MRI. 27 patients had other fractures. 18 had other findings on MRI, and 10 were interpreted as being negative, although one of these was a false negative. In a separate interobserver analysis, two experienced radiologists agreed on the diagnoses in 19/23 cases (kappa value 0.78). They agreed with a less experienced radiologist in 17/23 and 19/23 cases, respectively (kappa values 0.66 and 0.76).Interpretation MRI is a useful tool for demonstration of occult hip fractures. In the absence of a hip fracture, another explanation for the patient’s pain and disability will often be given.

Scanning and radiology of the carpal scaphoid bone.

The value of isotope scanning in patients with suspected fracture of the scaphoid bone of the wrist was examined. For this purpose comparable examinations were made of 50 patients using both radiography and isotope scanning. With a normal scan, the suspicion of fracture or other bone diseases can be excluded. Increased focal activity corresponding to the region of the scaphoid bone indicates the possibility of a fracture, even if a fracture cannot be seen in the initial X-rays.