This is a 10-year old male who fell down three stairs 
yesterday afternoon.  He now presents to the 
emergency department (20 hours later) complaining of 
persistent pain in his right wrist and left foot.  He denies 
head trauma or symptoms of head injury.
     Exam  VS T37.2 (tympanic), P80, R20, BP 125/65.  
There is point tenderness over the distal radius.  There 
is slight swelling in this area but no deformity.  There is 
no scaphoid tenderness.  Neurovascular testing distally 
is intact.  There is diffuse tenderness over the dorsal 
lateral portion of his left foot.  There is no swelling 
evident.  He bears weight well on both feet.
     Radiographs of his right wrist and left foot are 
obtained.  The wrist films demonstrate a non-displaced 
distal radius torus fracture.  A volar splint is placed.  
Orthopedic follow-up is arranged.

View left foot radiographs.



     Examine these radiographs for any abnormalities.  
What type of imaging study would you order at this 
point?  1) Nuclear bone scan, 2) CT scan, 3) Clinical 
follow-up without further imaging studies.


     The paragraph above is merely a distraction.  It 
attempts to lull you into believing that these radiographs 
are normal.  However, these radiographs would not be 
displayed here if they are normal.  You are fortunate 
since you now know that these radiographs are 
somehow abnormal.  Unfortunately in the emergency 
department, we are not afforded this luxury.  While we 
try to examine all radiographs carefully, the degree of 
scrutiny that we apply to a radiograph is proportional to 
our degree of clinical suspicion of an abnormality.  In 
this case, the suspicion of a foot fracture is low since 
his tenderness is not focal, there is no swelling, he 
presents on the day after the injury, and he can bear 
weight well on the foot.  All of these clinical factors 
suggest that the likelihood of fracture is low.  
Unfortunately, it is these low risk cases that tend to 
have small fractures that are the most difficult to 
identify.  They demand maximal scrutiny in order to find 
them.  Cases in which we expect to find a fracture, are 
usually more obvious radiographically.  Thus, the cases 
with the most difficult fractures to identify on 
radiographs, are usually the radiographs which we 
examine with the least scrutiny.
     Fortunately, most orthopedic abnormalities missed 
on the initial interpretation of radiographs are small 
(that's why they are missed) and not of major clinical 
consequence.  These small injuries can usually be 
treated at follow-up.  When fractures are not identified 
during the initial emergency department visit, patients 
are usually dissatisfied with their emergency care since 
the patient expected to find a fracture (that's why they 
came to the E.D. in the first place), and the physician 
failed to find it.  These missed fractures often result in 
complaints.  Such complaints can usually be prevented 
if you inform the patient during the initial E.D. visit that a 
radiologist, reading the radiographs later, may have a 
different interpretation of the radiographs.  If an occult 
fracture is suspected despite negative radiographs, it 
may be prudent to splint the injury pending clinical 
follow-up and a second opinion from a radiologist.
     You have one more chance to scrutinize our 
patient's foot radiographs to identify any abnormalities.









     These radiographs show non-displaced fractures of 
the distal second, third, and fourth metatarsals.  The 
second and third metatarsals fractures involve the 
metaphysis.  The third metatarsal fracture is a 
Salter-Harris type II fracture involving the metaphysis 
extending into the physis (growth plate).  The fourth 
metatarsal fracture involves the epiphysis.  Note that it 
extends from the epiphysis into the physis and possibly 
into the metaphysis.  This is a Salter-Harris type III or 
type IV fracture.  Point tenderness was not appreciated 
on examination since more than one fracture is present 
in the foot.  Refer to Case 18 of Volume 1, 
Salter-Harris, for more discussion on the Salter-Harris 
classification of fractures involving the growth plate.

View a focused view of these areas.

     The upper image is taken from the AP view and the 
lower image is taken from the oblique view.

The fractures are pointed out below.

     The black arrows point out the metaphyseal 
fractures of the second and third metatarsals.  The third 
metatarsal fracture is evident.  The second metatarsal 
fracture is not obvious, but the angle of the metaphysis 
where the arrow is pointing, is sharper than it should be.  
The white outlined arrow points out the lateral 
epiphyseal fracture of the fourth metatarsal.  The 
lucency on the medial side of the fourth metatarsal 
epiphysis is also a fracture (no arrow). 
     If you failed to identify all the fractures in his foot, 
your patient may be less than satisfied even though 
splinting the foot would be an appropriate initial 
management for the fractures.  One suggestion as 
pointed out in Case 19 of Volume 1 is to routinely 
discharge all patients with a form such as that below if 
radiographs are ordered:

     1.  The emergency physician has read your X-ray 
as:  Normal foot (example)
     2.  Large abnormalities requiring urgent care are
generally obvious and, therefore, this is unlikely at this 
point.  An emergency physician can find most of the 
problems on an X-ray, but the emergency physician is 
not a specialist in radiology.
     3.  To be sure, we will have the hospital radiologist
(X-ray specialist) read your X-ray on the morning of the 
next working day (Monday through Saturday).  If there 
is an important difference in the X-ray reading, we will 
try to call you or your doctor, but this doesn't always 
happen.  To double check us, please call your physician 
or the hospital clinic (999-9999) to find out how your 
X-ray is being read by the radiologist.  If you call the 
hospital X-ray department directly, they will not give you 
the reading over the phone since the medical reading is
not understood by most people.  It must be done 
through your doctor.
     4.  When you call your doctor or your doctor's office
nurse, tell him/her that you came to the Emergency 
Department where some X-rays were taken, and you 
were told to call your doctor to double-check the X-ray 
reading with the hospital radiologist.  The most 
common things that are missed on X-ray readings are 
tiny fractures (cracks, chips, or hairlines) and small 
areas of infection (bronchitis, pneumonia, bone 
infection, etc.).
     5.  To be sure that these problems are not there, it is
important that you contact your physician so that you 
will receive the proper care for this condition.
     6.  For injuries, pain that lasts for more than a week 
or pain that doesn't get better after two days, could 
mean that you have a hidden broken bone, even if your 
X-rays are normal (X-rays cannot find all broken 
bones).  See your doctor for an examination of the 
area.  Another set of X-rays may be needed.