This is a 24-year old female who comes to the 
emergency department with a chief complaint of foot 
pain.  She describes the location of the pain in the back 
part of her foot to the triage nurse.  The triage nurse 
informs the emergency physician about the foot pain.  
Radiographs of the foot are ordered.
     She returns from the imaging department with her 
foot radiographs.

View foot radiographs.

     Two views of her foot are shown here.  The anterior 
portion of the radiographs are not shown to conserve 
disk storage space.  Do you see anything wrong with 
these radiographs?  To avoid pitfalls, always look at the 
edges and corners of the films.


     These views of the foot demonstrate fractures of the 
fibula and posterior tibia.  These fractures would be 
more easily seen on proper views of the ankle, 
however, foot films were ordered instead.  These 
fractures are difficult to see on the views obtained.

View focused magnified view of the fracture sites.    

     The black arrows point to the fracture sites in the 
fibula and tibia in the upper radiograph.  The white 
arrow points to the fracture site in the fibula visible in 
the lower radiograph.  Look at the original radiographs 
again above.
     After the patient returned from the imaging 
department, her radiographs were reviewed and no 
fractures were noticed on the radiographs.  However, 
after examining her foot, it was evident that she most 
likely had an injury of her ankle.  She was sent back to 
the imaging department for radiographs of her ankle 
which demonstrated the tibia and fibula fractures noted 
above.  In retrospect, these fractures were also noticed 
on her foot films.
     Ordering radiographs from the triage room is a 
common practice in many emergency departments.  
This can reduce the waiting time for patients so that 
their diagnostic studies can be completed more 
efficiently.  However, realize that the triage process 
focuses on prioritizing care rather than making a final 
diagnosis.  The patient's chief complaint may at times 
be deceiving.  As in this case it may lead one to order 
suboptimal radiographic views without an examination.  
When the patient returns with radiographs in hand, 
there may be a tendency to focus on the radiographs 
and not on the patient.  By depending solely on 
radiographs and a triage assessment, one may miss 
the diagnosis.  Realize that patients who are referred 
directly to the imaging department from triage must still 
be examined upon return to ascertain that the proper 
radiographic images were ordered.  Additionally, the 
radiographic interpretation should always be correlated 
with the patient's clinical findings.  Injuries at other body 
sites must also be evaluated clinically, for example, 
head trauma following an extremity injury.
     Another error of omission that is commonly made is 
on the patient who arrives with a large splint applied to 
a deformed extremity (often applied by paramedics).  
The patient is usually in severe pain making an 
examination painful for the patient.  Such patients are 
commonly sent for radiographs where the fracture 
diagnosis is made and an orthopedic surgeon is called.  
Before calling the orthopedic surgeon, one should 
ascertain that this is indeed a closed fracture.  The 
splint must be carefully removed and the extremity must 
be inspected for any skin punctures or wounds.  
Occasionally, cotton or padding will stick to a wound, 
hiding it.  All cotton and padding must also be removed 
to ascertain that the skin surface is intact.
     Although this computer program is called Radiology 
Cases in Pediatric Emergency Medicine, this patient is 
clearly an adult.  However, the same process is 
commonly employed for children and the same type of 
fracture can still be seen in children and teens.  This 
case just happened to occur in a young adult, but it 
could very well have occurred in a child or teen as well.