Easily Missed Radiologic Injuries

R3

Reference
1.

Missed Radiologic Injuries

Michelle Lin, MD, San Francisco General Hospital, Emergency Services

2.

Radiologymasterclass

http://www.radiologymasterclass.co.uk/

eORIF http://eorif.com/
4. Image Interpretation Course
3.

http://www.imageinterpretation.co.uk

Introduction

Missed orthopedic injuries, such as fractures and

dislocations, comprise the largest source of
malpractice claims in the emergency department
Pennsylvania Hospital Insurance Company (19771981): 19% of 200 ED malpractice cases were
due to misinterpretation of radiographs.
(Trautlein et al.)
Chicago (1975-1994): Retrospective study of
18860 malpractice claims showed 12% involved
radiology cases,
Massachusetts Joint Underwriters Association:
Missed fractures comprised 20% (during 19801987) and 10% (1988-1990) of malpractice
claims. (Karcz et al, 1993)

Occult lesion

Not readily visible on plain radiographs using

standard techniques using standard technique
Clinical important
1. Change in management
2. Significant risk of complications if missed
Most common Errors:
1. Failure to order right test
2. Misinterpretation of the test
3. Physical examination is still important

Errors in Radiograph Interpretation

Commonly missed, high-risk injuries on

radiographs can be remembered by using
mnemonic DOH"

1. Shoulder

Shoulder- Normal Anatomy

Y view

Axillary view

The humeral head and glenoid rim

Anterior shoulder dislocation

Posterior shoulder dislocation

Posterior shoulder dislocation

Account for only 2-4% of all shoulder dislocations

Posterior dislocation may be missed initially on
frontal radiographs in 50% of cases, as the
humeral head appears to be almost normally
aligned with the glenoid
The absence of external rotation on images in a
standard shoulder series is a clue to posterior
dislocation, the internally rotated humeral head
takes on a rounded appearance known as the
lightbulb sign
Axillary, scapular Y projection
are needed for confirmation

Wrist and Hand

What's Wrong ?

What's Wrong ?

Wrist-Normal Anatomy

PA View (R Wrist): 3 smooth arcs along carpals

Intercarpal distance < 3 mm

Wrist-Normal Anatomy (LAT)

Alignment: Smooth articulation of distal radius to lunate,

lunate to capitate, and capitate to 3rd metacarpal
Scapholunate angle < 30-60 degrees

Hand- Normal Anatomy

Scaphoid Fx

Triquetrum fracture

Perilunate dislocation

Carpal-metacarpal dislocation

Elbow

What's Wrong ?

Elbow-Normal Anatomy

Normal elbow anatomy

1. Capitellum articulates with the radial head (lateral).

2. Trochlea articulates with the olecranon (medial).
3. The articulating surfaces of the distal humerus are offset anteriorly
to the humeral shaft ( lateral film):

Dx: Radial head Fx

What's more ?

Radial head fracture with abnormal fat pad sign!!

Hip

What's Wrong ?

PELVIS / HIP

Normal hip anatomy

Shenton's line : formed by

the medial edge of the
femoral neck and the
inferior edge of the
superior pubic ramus
Loss of contour of
Shenton's line is a sign of
a fractured neck of femur
IMPORTANT NOTE:
Fractures of the femoral
neck do not always cause
loss of Shenton's line

Femoral neck fracture

One more exercise

Femoral neck fracture

Knee

What's Wrong ?

Normal Anatomy of Knee

1. Lateral tibial Plateau

2. Lateral intercondylar
eminence
3. Medial intercondylar
eminence
4. Medial tibial plateau

Normal Anatomy of Knee

What do you see?

Tibial plateau fracture

What do you see?

No visible fracture line

Depressed tibial plateau contour
Lipohaemarthrosis (fat and blood in the joint)

Bipartite patella - not a fracture

1.The patella is bipartite (in 2 parts) - a common normal variant

2. Physical examination is important !!
3. Injury to the interface of the 2 components is possible to be
symptomatic

Ankle and Foot

What's Wrong ?

Normal anatomy of foot & ankle

AP: Normal alignment of the medial side of 2nd

metatarsal with the intermediate cuneiform
Oblique - Normal alignment of the 3rd metatarsal
with the lateral Cuneiform
Be aware of Lisfranc ligament

Ankle

Lateral View:
Bohlers angle
1 superior aspect of the
posterior calcaneal
tuberosity
2 superior subtalar
articular surface
3 superior aspect
of the anterior calcaneal
process

Normally is 20-40 degrees

A Bohlers angle < 20 degrees
implies an occult calcaneal fracture.

Lisfranc dislocation

Bohler angle <20 degree

Calcaneous fracture

Questions?

Thank you