Priority Topic: Fractures

Key Feature 3: In patients with suspected fractures that are prone to have normal X-ray findings (ex: scaphoid fractures in wrist injuries, elbow fracture, growth plate fracture in children, stress fractures), manage according to your clinical suspicion, even if X-ray 
Skill: Clinical Reasoning, Selectivity
Phase: Treatment

Key Feature 4: In assessing elderly patients with an acute change in mobility (i.e., those who can no longer walk) and equivocal X-ray findings (ex: no obvious fracture), investigate appropriately (ex: with bone scans, computed tomography) before excluding a fracture. 
Skill: Clinical Reasoning
Phase: Investigation

So that key feature is definitely not a complete sentence, and just like a suspected fracture with a negative x-ray, it leaves you hanging. X-rays are never 100% sensitive for fractures, sometimes not even approaching this depending on the fracture type, and there are fractures that have a higher risk of negative consequences if the bone/affected joint is not immobilised. Let's go through some of the more common circumstances in which having a higher index of suspicion of fracture is warranted.

1. FOOSH with wrist +/or elbow pain
   • When a patient describes having fallen on an outstretched hand (FOOSH) with the wrist in dorsiflexion, and with ongoing radial-sided wrist and/or elbow pain, they must be examined for signs of a scaphoid or radius fracture. 
     • FOOSH with radial-sided wrist pain
       • Plain radiographs to order to look for a scaphoid fracture include orthogonal PA and lateral +/- oblique and scaphoid views of the wrist. 
       • False negative rate of plain radiographs for scaphoid fractures, within 2-6 weeks of injury, hovers at around 20% (!)
       • If plain radiographs are negative and more advanced imaging is available, this would be warranted. Although many physicians may use an immobilise-and-reassess approach, opting for further imaging with MRI, CT, or bone scan is more cost-effective than empiric immobilization. Although the cost of imaging is greater up-front, the overall cost is greater with the immobilise-and-reassess approach, as accrued by costs for the supplies to immobilize, for follow-up visits, and for loss of productivity secondary to unnecessary immobilization. 
       • If advanced imaging is not available and a scaphoid fracture cannot be ruled out, the patient requires immobilization of the scaphoid using a thumb spica splint or cast for 7 to 14 days followed by reimaging 
     • FOOSH with elbow pain
       • Plain radiographs to look for a radius fracture includes orthogonal (PA and lateral) views of the wrist and elbow +/- oblique lateral view of the elbow.
       • Elevated anterior and/or posterior elbow fat pads may be the only indication of a proximal radial fracture. 
       • If there is no sign of fracture and full range of motion of the elbow joint, then no further investigation or management is necessary. If there is limited range of motion, then further imaging is warranted to detect an occult fracture, because in the setting of proximal radius fracture and decreased joint range of motion, orthopaedic surgery may be indicated. 
2. Possible growth plate fracture
   1. In pediatric patients, the growth plate is still open and at risk of being injured. There must be a high index of suspicion for a growth plate injury because if present, it can lead to growth arrest (the cells that are dividing and elongating the bone can no longer do their job). This is a bad thing. It requires a high index of suspicion not only because it's bad though, but because the fractures that are more likely to disrupt the growth plate are also the ones that are most likely to appear normal on imaging. These are classified as Type I Salter-Harris fractures. (See image at the bottom of the post.)
   2. In a pediatric patient with normal radiographs but focal tenderness over the growth plate, management should ensue as if there is a radiographically detected fracture. X-rays are then repeated 7 days after injury. 
3. Possible stress fractures
   1. ​Stress fractures occur because of repetitive use and strain on the bone, leading to cracks in the outer layer of the bone (periosteum). A high index of suspicion is warranted in patients who perform repetitive physical activity and who complain of bony pain. (See table below for stress fractures that are more commonly associated with certain sports.)
   2. Plain radiographs are typically normal until 1-2 weeks after symptom onset. A wait and reassess approach can again be taken, or further characterization with MRI may be pursued depending on available resources.
4. Hip fractures in the elderly
   
   1. ​These are so common and carry such a high burden of morbidity and mortality, they just can't afford to be missed. In an elderly patient who is complaining of new hip pain (or maybe who has decreased cognitive abilities and is unable to express this but is suddenly not willing or able to walk), there must be a high index of suspicion for hip fracture. 
      
   2. First-line imaging is to obtain 2 views: AP pelvis (to be able to compare both hips) with maximal internal rotation and lateral view of the hip. If x-rays are unremarkable, then further imaging is warranted given the clinical picture (MRI is ideal)