Orthopedic X-Rays most commonly missed

Transcription

1 Orthopedic X-Rays most commonly missed Vukiet Tran, MD, MHSc, MBA University Health Network Toronto, Canada 1

2 COI Disclosure I am the current Medical Director for Best Doctors Canada. Presenter: Dr. Vu Kiet Tran

3 Disclosure I missed 80-90% of these cases 3

4 I have made many 4

5 More mistakes to come 5

6 Our work environment 6

7 Chaotic 7

8 Distraction 8

9 Objectives Recognize the most frequent Xrays missed by ED health care professionals Understands the factors that lead to misinterpretation Learn about some radiographic signs that allows one to mitigate the rate of misses Apply tools learned to reduce the miss rate 9

10 Objectives Recognize the most frequent Xrays missed by ED health care professionals Understands the factors that lead to misinterpretation Learn about some radiographic signs that allows one to mitigate the rate of misses Apply tools learned to reduce the miss rate Do as I say and not as I do! 10

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12 Let s start! 12

13 Scaphoid fractures No longer commonly missed! 13

14 Which is the normal? 14

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16 The Elbow Anatomic Lines Anterior Humeral Line o Passes through middle third of capitulum Proximal Radial Line o Bissects through centre of capitulum

17 Is there a Fracture? 17

18 Radial head fractures are often missed 18

19 Tip 1 Know exactly what you are searching for before you look at the film itself 19

20 Tips 2 Always get proper perpendicular views (AP and lateral) 20

21 Hurt my wrist swinging a club Golf clubs, Baseball bats or Direct Blow to palm Pain with Gripping Pain at Hypothenar Eminence

22 Hamate Bone Fracture Fractures of the Hamate Body can be seen by X-Ray o LESS Common than Fractures of the Hook

23 Hook of Hamate Fracture Fractures of the Hamate Hook require a special X-Ray (or CT) o Carpal Tunnel View o 20 degree Supinated Lateral View

24 Hook of Hamate Pull Test Examiner pulls on 4th and 5th digits Flexor Digitorum Profundus tendons will displace the broken hook and reproduce exact severe pain Or you can push on it!

25 What is the injury? 25

26 Scapho-Lunar Dissociation Unstable Rarely diagnosed o Replaces scaphoïd fracture FOOSH Scapho-lunar Pain 26

27 Scapho-Lunar Dissociation Terry Thomas 27

28 Scapho-Lunar Dissociation 1. Terry-Thomas Shortening of scaphoïd Cortical Ring of the scaphoïd Trapesoidal Semi-lunar Taleisnik V N < 3 mm N 28

29 Scapho-Lunar Dissociation Closed fist 29

30 What is the injury? 30

31 Lunate Dislocation Lateral view Disrupt 3 Cs Spilled teacup Capitate rest on radius PA view Piece of pie Carpal fractures 31

32 What is the injury? 32

33 Disruption of C s Spilled teacup Capitate rest on Radius 33

34 Tip 3, 4, 5, 6 Be aware of specific occult fracture/dislocation radiographic signs Know what a normal should look like Look for the second injury/fracture Avoid being distracted 34

35 What is the most commonly missed major joint dislocation? Posterior Shoulder Dislocation 2% of shoulder dislocations 60% missed initially Associated with o Epilepsy (Seizures) o Electricity o Blow to anterior shoulder

36 Which is normal? Which is abnormal?

37 The Power of the Axillary View!

38 Male with ankle pain 38

39 Female with ankle pain 39

40 Medial Dome of Talus 40

41 Lateral Process of Talus 41

42 Posterior Process of Talus 42

43 Ankle sprain mimics Talar dome o Medial dome o Lateral dome o Anterior process o Posterior process o Lateral process Anterior process of the Calcaneum 43

44 Use of the OXawa ankle rule Malleolar zone A. Posterior edge or tip of lateral malleolus 6 cm Midfoot zone. Lateral view C. Base of fifth metatarsal Inability to bear weight after the injury of during the examination 6 cm B. Posterior edge or tip of medial malleolus ILLUSTRATION BY DAVID KLEMM Medial view. D. Navicular 44

45 Tip Your history and physical exam trumps any radiographic finding (or lack thereof) For the ankle, apply the Ottawa Ankle Rule For any lower extremity injury, always observe the gait and watch the patient walk Keep in mind some of the most common misses by ED doctors 45

46 Other missed injuries Supracondylar fractures DRUJ injuries Triquetum fractures Volar plate fractures (Phalanges) Hip fractures Patella injuries Tibial plateau fractures Calcaneal compression fractures 46

47 Diagnostic errors in the ED Diagnosis Number of errors Percentage Fractures Dislocations 19 2 Tendon injuries Nerve injuries Ligament injuries Foreign bodies Other trauma Non- trauma (MI, abdo pain) Incidental findings Emerg Med J 2001; 18:

48 Why do I talk about this? 48

49 Diagnostic errors in the ED Diagnosis Number of errors Percentage Fractures Dislocations 19 2 Tendon injuries Nerve injuries Ligament injuries Foreign bodies Other trauma Non- trauma (MI, abdo pain) Incidental findings Emerg Med J 2001; 18:

50 Diagnostic errors in the ED Areas Shoulder Elbow Wrist Hand Hip Knee Ankle Foot Spine Specific injury Clavicle Radial Head, Supracondylar Distal radius, Greenstick radius, Scaphoid, Triquetrum Base of 5 th metacarpal, Thumb, Proximal phalange of fingers, Volar plate fracture Neck of femur, One or more pubic rami Tibial plateau Lateral malleolus, Calcaneum, Avulsion fractures Base of 5 th metatarsal Odontoid, Jefferson fracture Emerg Med J 2001; 18:

51 Misread rate by ED docs Author Year Accuracy Clinically significant Comments Fleischer et al % 1.2% Pediatric ED Mucci et al % Overton et al % Graton et al % ED residents Walsh- Kelly et al % 1.4% Adult ED Brunswick et al % Adult ED Preston et al % Adult ED Berman et al % 0.8% Adult trauma Benger et al % 0.3% Adult ED Petinaux et al % 0.056% Adult ED Misread rates vary from % Significant misread rates vary from % 51

52 Summary 52

53 How to avoid misinterpretation of an Xray 53

54 Examine the patient first 54

55 The clinical findings trump everything 55

56 Examine the joint above and below the fracture 56

57 Avoid being distracted 57

58 Know what you are looking for 58

59 Obtain multiple views of the same are of interest 59

60 Be familiar with specific radiographic signs 60

61 Look for the second or third fracture 61

62 Look for the ring disruption 62

63 Pay more axention to the common misses 63

64 Thank you 64