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Occult Fractures

Gregory W. Hendey, MD, FACEPProfessor of Clinical EM

UCSF Fresno

Objectives:� To discuss plain film and physical findings

that suggest an occult fracture� To recognize clinical scenarios that are high

risk for an occult fracture� To discuss the evidence-based approach to

evaluating patients for an occult fracture

High Risk!� Kachalla, Annals of EM, 2007:

� 122 ED malpractice claims, 4 insurers� Most common “Missed Dx”�#1-Fracture, #2-Infxn, #3-MI

� Most common Errors:�Failure to order right test (58%)�Radiologic study (61%): #1-Xray

�Misinterpretation of test (37%)�Radiologic study (66%): #1-Xray

““““Occult”””” Fracture?� Not readily visible on plain radiographs,

using standard techniques� Clinically important� Change in management� Significant risk of complications if missed

� Missed Fracture = most common source of malpractice lawsuits in EM

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The Plan:� 3 clinical scenarios to illustrate common,

occult fractures:� Hip� Elbow� Wrist

THE HIP

Case 1:� 75 yo F fell onto her L side� Pain in L hip with weight bearing

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What should I do next?

B on e

s c an

C T s c a

n

M RI

S i gn o

u t an d

g . . .

5% 7%12%

76%1. Bone scan2. CT scan3. MRI4. Sign out and go to lunch

Occult hip fracture� Common, and clinically important� Bone Scan (?) vs CT vs MRI

� MRI is most supported by evidence� All three are superior to plain films� Local resources impact choice

MRI� Frihagen, Acta Orthop, 2005:

� 100 pts, hip trauma, negative plain films� All had MRI� 46 Hip Fx� 30 had surgery

MRI:

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� Can CT exclude hip fx?� Rapid advances in technology� As good as MRI?

MRI vs CT:� Lubovsky, Injury, 2005:� 6 pts with suspected fx, negative Xrays� All had MR and CT (slice?)� 5 of 6 had fx. CT “ misdx’d” three.

• Greater tuberosity fx in 3 who had inter-trochanteric fx by MRI

� Case series (not yet published)� 4 cases, negative CT, positive MRI

82 year old female: CT:

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MRI: Occult hip fracture:

� MRI is still the ““““gold standard””””

�What if I only have access to CT?

THE ELBOW Case 2:� 31 yo M crashed his bicycle� c/o R elbow pain� No deformity, slightly swollen� Decreased ROM

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What occult fracture is hiding in this adult elbow?

R ad i a l

h e ad

S u pr a c

o n dy l a r

O l ec r a

n o n

C al c a n

e u s

62%

1%

12%

25%

1. Radial head 2. Supracondylar3. Olecranon 4. Calcaneus

Approach to the Elbow:

� 90 degree lateral

1) Fat pads• Bulging anterior• Any posterior

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2) Radio-capitellar lineMonteggia fx:

3) Anterior Humeral Line

Kids: Anterior Humeral Line

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THE WRIST Case 3:� 31 yo M struck by martial arts instructor� c/o wrist pain� Snuffbox tenderness

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What is your next move?

T hu m

b s pi c a ,

f . . .

C T s c a

n

M RI

S i gn o

u t an d

g . . .

68%

3%

14%15%

1. Thumb spica, follow up2. CT scan3. MRI4. Sign out and go to lunch

Scaphoid fracture� Most common carpal fracture� 10-20% occult

� Distal blood supply � Delayed complications:� Non-union� Avascular necrosis

Best way to find occult fx?� Bone scan: � Traditional—but obsolete

� MRI: � Better than bone scan in multiple studies

� CT: � As good as MRI?

MRI vs CT:� Memarsadeghi, Radiology, 2006:

� 29 pts, neg X-ray, had CT (4) and MRI� Gold std: plain films at 6 wks� 11 scaphoid fx� MR found 100%, CT found 8/11 (73%)

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More CT studies:� Ty et al., Hand, 2008

� 28 pts, only used CT (no MRI)�4 scaphoid fx, 10 others (radius, carpals)

� No missed fx, but 8/14 neg CT lost to f/u� Cruickshank, Emerg Med Aus, 2007:

� 47 pts, CT (64): 7 scaphoid fx, 10 others� MRI (prn) found one more fx (capitate)

Occult scaphoid fx:� CT vs MRI not resolved� Splint and follow-up vs Imaging today?

Summary:� Clinical situations that suggest an occult

fracture� Evidence-based approach to evaluating

patients for an occult fracture

� Thank you!

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