“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.

If 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

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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.