“X-ray normal” is not a diagnosis. While most ED patients with negative extremity X-rays do not have a fracture, a few will. As clinicians, we see normal X-rays routinely on every shift. We should neither be falsely reassured by them nor unduly afraid of them. Combining the patient’s history with risk factors and the physical exam will determine our proper level of concern.
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ACEP Now: Vol 39 – No 03 – March 2020If significant concern for a fracture remains after negative X-rays, the ideal ED management strategy depends on the diagnosis, the patient, and available resources.
Worrisome diagnoses in less physically robust patients tend to require more urgent diagnostic confirmation. However, in many cases, sturdy patients with a suspected occult fracture can be safely and appropriately managed with an ED plan to treat for the fracture and arrangement of close follow-up.
References
- Baldassarre R, Hughes T. Investigating suspected scaphoid fracture. BMJ. 2013;346:f1370.
- Suh N, Grewal R. Controversies and best practices for acute scaphoid fracture management. J Hand Surg Eur Vol. 2018;43(1):4-12.
- Mallee WH, Wang J, Poolman RW, et al. Computed tomography versus magnetic resonance imaging versus bone scintigraphy for clinically suspected scaphoid fractures in patients with negative plain radiographs. Cochrane Database Syst Rev. 2015;(6):CD010023.
- Beeres FJ, Rhemrev SJ, den Hollander P, et al. Early magnetic resonance imaging compared with bone scintigraphy in suspected scaphoid fractures. J Bone Joint Surg Br. 2008;90(9):1205-1209.
- Kwee RM, Kwee TC. Ultrasound for diagnosing radiographically occult scaphoid fracture. Skeletal Radiol. 2018;47(9):1205-1212.
- Kiel CM, Mikkelsen KL, Krogsgaard MR. Why tibial plateau fractures are overlooked. BMC Musculoskelet Disord. 2018;19(1):244.
- Lewis PM, Waddell JP. When is the ideal time to operate on a patient with a fracture of the hip? a review of the available literature. Bone Joint J. 2016;98-B(12):1573-1581.
- Weller I, Wai EK, Jaglal S, et al. The effect of hospital type and surgical delay on mortality after surgery for hip fracture. J Bone Joint Surg Br. 2005;87(3):361-366.
- Je S, Kim H, Ryu S, et al. The consequence of delayed diagnosis of an occult hip fracture. J Trauma Injury. 2015;28(3):91-97.
- Iordache SD, Goldberg N, Paz L, et al. Radiation exposure from computed tomography of the upper limbs. Acta Orthop Belg. 2017;83(4):581-588.
- Biswas D, Bible JE, Bohan M, et al. Radiation exposure from musculoskeletal computerized tomographic scans. J Bone Joint Surg Am. 2009;91(8):1882-1889.
- Radiation dose to adults from common imaging examinations. American College of Radiology website. Available at: https://www.acr.org/-/media/ACR/Files/Radiology-Safety/Radiation-Safety/Dose-Reference-Card.pdf. Accessed Feb. 13, 2020.
Dr. Sayal is a staff physician in the emergency department and fracture clinic at North York General Hospital in Toronto, creator and director of CASTED ‘Hands-On’ Orthopedic Courses, and associate professor in the department of family and community medicine at the University of Toronto.
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