CLINICAL RISK REDUCTION


Simon Bennet and Michael Kelly highlight some common pitfalls in the assessment and management of acute fractures


Statistics from Edinburgh have shown that approximately one per cent of the population sustain a fracture each year. T e consequences of missed diagnosis range from minor pain and inconvenience for patients, to adverse long-term outcomes and chronic functional limitation due to fracture non-union, joint stiff ness and the need for later, more complex surgery. Missed fractures form the majority of diagnostic errors made in A&E. Most doctors who have worked in A&E will remember their consultants at some point asking them to “take another look” at a certain patient’s X-ray, gently informing them they have missed a fracture. Failure to detect an abnormality on an X-ray is the most common error, but failure to take an X-ray due to inadequate examination or appreciation of an injury, or ordering the wrong views also occur frequently. T is is particularly true of junior medical staff working in A&E or general practice for the fi rst time.


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Clinical diagnosis and patterns of injury T e diagnosis of an acute fracture, like much of clinical medicine, is based upon an accurate history and a focused clinical examination, followed by appropriate imaging. Of crucial importance is the appreciation of injury mechanisms and therefore being alerted to associated injuries. Oſt en the history taken will be brief and may miss important


features. T e identifi cation of higher risk mechanisms of injury and patient groups (such as the elderly and others susceptible to fragility fractures) will lead to a greater index of suspicion for certain injuries. For example, falls from a height over 5m are associated with calcaneal fractures. Moreover, this should prompt a search for associated injuries such as pelvic and spinal fractures, remembering that the presence of one major injury may distract both patient and doctor from other injuries. Shoulder pain


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CUTE musculoskeletal injuries form a signifi cant proportion of the workload in both general practice surgeries and accident and emergency departments.


following a seizure or electrocution is classically associated with a posterior dislocation of the shoulder that can be easy to miss on X-ray. T e majority of presentations, however, will occur following relatively minor trauma. In the assessment of upper limb injuries, the history should


clarify the site of pain and swelling and any associated loss of function or movement. Commonly missed hand and wrist injuries include volar plate avulsion fractures, ulnar collateral ligament injuries, fractures of the base of the thumb and scaphoid fractures. Missing these oſt en subtle injuries can lead to chronic pain, early osteoarthritis and reduction of hand function. Examination should elicit signs of bony tenderness, swelling, reduced range of movement and joint laxity. Clinicians should therefore adopt a low threshold for obtaining appropriate X-rays and follow-up X-rays where appropriate (e.g. suspected scaphoid injuries). T e evaluation of forearm injuries should include a careful


examination of both the wrist and elbow joints, as a fracture of one bone can lead to shortening and the resultant dislocation of the other. If the radius is fractured and shortens, the ulna tends to dislocate at the distal radio-ulnar joint (Galleazi injury). In the case of an ulna fracture, the radial head dislocates from the radiocapitellar joint at the elbow (Monteggia injury). Patients sustaining lower limb injuries who cannot weight-bear


should be considered to have a fracture until proven otherwise. T e Ottowa ankle rules, when applied correctly, have a very high sensitivity for identifying ankle fractures. T ese involve obtaining ankle X-rays when a patient has the triad of malleolar pain, tenderness and inability to weight-bear. T is principle can also be logically applied to other areas of the lower limb. Knee injury assessment should identify the presence of a


haemarthrosis, which the patient will report as immediate swelling in the joint, rather than a reactive eff usion taking many hours to develop. In the absence of an obvious fracture, a high suspicion of collateral and cruciate ligament injuries or a chondral injury


SUMMONS


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