Tips for Diagnosing Occult Fractures in the Emergency Department

BELOW: Day 1 – normal RIGHT: Week 3 – subtle periosteal reaction lateral aspect distal tibia

Left: Day 1 – normal
Right: Week 3 – subtle periosteal reaction lateral aspect distal tibia

Case 3: occult distal radius fracture

The 69-year-old woman who fell on her outstretched hand: When she returned one week later, she was still tender and swollen and looked like she had a distal radius fracture. She was kept in a splint, and X-rays repeated at four weeks revealed the fracture.

BELOW: Day 1 – normal RIGHT: Week 4 – sclerosis across distal radius

Left: Day 1 – normal
Right: Week 4 – sclerosis across distal radius

Case 4: occult lateral tibial plateau fracture

The 72-year-old woman who twisted her knee: When she returned one week later, she was still unable to bear weight on the knee, and she was swollen and tender over the lateral joint line. Follow-up imaging revealed a lateral tibial plateau fracture.

$BELOW: Day 1 – no definite fracture RIGHT: Day 5 – CT: mildly depressed lateral tibial plateau$

Left: Day 1 – normal
Right: Week 4 – sclerosis across distal radius

Key points

Determine the force and mechanism of injury
Appreciate the “quality of bone” to which that force was applied
Examine patients to determine tenderness, range of motion, etc.
Then look at the x-rays
Keep in mind, if there is a higher pre-test probability and a negative X-ray, the patient still may have a fracture

Our next column will deal with management strategies for suspected occult fractures in the emergency department.

Dr. Sayal is a staff physician in the emergency department and fracture clinic at North York General Hospital in Toronto, Ontario; 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.