occult ortho injuries Lauren M Westafer, DO, MPH, MS

Transcription

1 hiding in plain sight occult ortho injuries Lauren M Westafer, DO, MPH, MS

2 No financial disclosures No commercial product discussion Photo: Zoltan Horlick

3 Recognize subtle findings on plain films that can carry significant morbidity and change patient management with orthopedic injuries. Determine when EM providers must order further imaging (i.e. CT, MRI) to further evaluate an otherwise assumed "rmal x-ray. Implement an algorithmic approach to identifying commonly missed, radio-occult orthopedic injuries in the ED (i.e. scaphoid fractures, hip fractures in the elderly, calcaneus fractures, radial head fractures, and occult traumatic knee injuries, etc.). Photo: Matteice David

4 a rmal x-ray doesn t rule out fracture if a patient can t bear weight, think about CT or, at least splinting and close follow up Photo: Matteice David

5 70 y/o male slipped on ice left hip pain Photo: NTR23

6 Phooto: Booyabazooka

7 hip fracture Rehman H et al. Imaging of occult hip fractures: CT or MRI?. Injury. 2016;47(6):

8 hip fracture hip pain negative x- ray

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10 hip fracture hip pain negative x- ray able to bear weight

11 weight bearing

12 hip fracture hip pain negative x- ray able to bear weight CT hip

13 CT the common final pathway ~88% sensitive MRI may be better, but time $$ access Hakkarinen DK et al. J Emerg Med. 2012;43(2):303-7.

14 hip fracture hip pain negative x- ray able to bear weight CT hip low clinical suspicion for fracture, x-ray really negative? probably t a fracture

15 occult hip fracture 2.5% occult hip fracture 1.7% Gill et al. ScientificWorldJournal. 2013; 2013:

16 hip fracture positive hip pain negative x- ray able to bear weight CT hip low clinical suspicion for fracture, x-ray really negative probably t a fracture

17 22 y/o male FOOSH while tailgating at football game wrist pain

18 Photo: James Hellman

19 scaphoid fracture x

20 scaphoid fracture fall on outstretched hand wrist x-ray with obvious fracture

21

22 scaphoid fracture fall on outstretched hand wrist x-ray with obvious fracture snuff box tenderness

23 snuff box tenderness + LR 1.5 ( ) -LR ( )

24 snuff box tenderness t a scaphoid fracture

25 scaphoid fracture fall on outstretched hand wrist x-ray with obvious fracture snuff box tenderness scaphoid fracture VERY unlikely MRI / CT? or thumb spica splint + ortho follow up Malee W et al. J Bone Joint Surg Am Jan 5;93(1):20-8

26 CT vs MRI sensitivity 72% sensitivity 88% Mallee WH et al. Cochrane Database Syst Rev. 2015;(6):CD

27 thumb spica + ortho f/u

28 scaphoid fracture fall on outstretched hand wrist x-ray with obvious fracture snuff box tenderness scaphoid fracture VERY unlikely MRI / CT? or thumb spica splint + ortho follow up Malee W et al. J Bone Joint Surg Am Jan 5;93(1):20-8

29 30 y/o female fall during rugby game elbow pain Photo: Marybeth Sclafini

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31 radial head fracture x

32 radial head fracture traumatic elbow pain obvious fracture posterior fat pad or elevated anterior fat pad

33 elevated anterior fat pad sail sign posterior fat always pad abrmal O'Dwyer H et al. J Comput Assist Tomogr. 2004;28(4):562

34 radial head fracture Look very carefully for fracture, CT if can t see on x-ray traumatic elbow pain obvious fracture posterior fat pad or elevated anterior fat pad

35

36 radial head fracture Look very carefully for fracture, CT if can t see on x-ray positive traumatic elbow pain obvious fracture posterior fat pad or elevated anterior fat pad Radiocapitella r view neg CT elbow

37 CT the common final pathway

38 radial head fracture Look very carefully for fracture, CT if can t see on x-ray positive traumatic elbow pain obvious fracture posterior fat pad or elevated anterior fat pad Radiocapitella r view neg CT elbow

39 78 y/o female motor vehicle collision knee pain Photo: clement127

40

41 tibial plateau x

42 tibial plateau treat x-ray with obvious fracture Assess lateral joint space, lipohemarthrosis x

43 tibial plateau presen t treat Re-inspect x-ray for fracture presen t x-ray with obvious fracture Assess lateral joint space, lipohemarthrosis ne present ne present concerning mechanism or unable to bear weight without other clear injury eval and treat for other injuries ortho follow up CT knee without contrast OR discharge n weightbearing with close ortho follow up x

44 visible on retrospective review Photot: Jeremy McWilliams Kiel et al. BMC Musculoskeletal Disorders201819:244

45 een or suspected on retrospective revie Photot: Jeremy McWilliams Kiel et al. BMC Musculoskeletal Disorders201819:244

46 Case courtesy of RMH Core Conditions, Radiopaedia.org. From the case rid: 33626)

47 lipohemarthrosis Photo courtesy of Dr Victoria Ho

48 lipohemarthrosis 63% Lee JH, Weissman BN, Nikpoor N et-al. Lipohemarthrosis of the knee: a review of recent experiences. Radiology. 1989;173 (1):

49 tibial plateau treat x-ray with obvious fracture Assess lateral joint space, lipohemarthrosis ne present concerning mechanism or unable to bear weight without other clear injury x

50 concerning mechanism fall from height MVC high energy mechanism ped vs car fall in elderly Lee JH, Weissman BN, Nikpoor N et-al. Lipohemarthrosis of the knee: a review of recent experiences. Radiology. 1989;173 (1):

51 tibial plateau presen t treat Re-inspect x-ray for fracture presen t x-ray with obvious fracture Assess lateral joint space, lipohemarthrosis ne present ne present concerning mechanism or unable to bear weight without other clear injury eval and treat for other injuries ortho follow up CT knee without contrast OR discharge n weightbearing with close ortho follow up x

52 CT the common final pathway

53 tibial plateau presen t treat Re-inspect x-ray for fracture presen t x-ray with obvious fracture Assess lateral joint space, lipohemarthrosis ne present ne present concerning mechanism or unable to bear weight without other clear injury eval and treat for other injuries ortho follow up CT knee without contrast OR discharge n weightbearing with close ortho follow up x

54 a rmal x-ray doesn t rule out fracture look for subtle signs/re-inspect x-ray

55 if a patient can t bear weight, think about CT

56 or, at least splinting and close follow up

57 RADIOLOGY Impression: Socks cant rule out stockings, slippers, lymphangiomyomatosis. Recommend clinical correlation.

58 @LWestafer FOAMcast shortcoatsinem.blogspot.c

59 scaphoid fracture fall on outstretched hand wrist x-ray with obvious fracture snuff box tenderness scaphoid fracture VERY unlikely MRI or thumb spica splint + ortho follow up

60 treat traumatic knee pain x-ray with obvious fracture concerning mechanism or unable to bear weight without other clear injury eval and treat for other injuries ortho follow up CT knee without contrast OR discharge n weightbearing with close ortho follow up x

61 hip fracture positive hip pain negative x- ray able to bear weight CT hip low clinical suspicion for fracture probably t a fracture