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What’s The Diagnosis # 19

Had another patient arrive by ambulance with hip pain after falling on the ice. We seem to be getting a lot of hip pain patients lately.

Pain prevented him from walking. We got x-rays that the radiologist read as normal. But the patient still couldn’t walk. Look at the x-rays and see if you can find the problem. Scroll down for the answer.

I just realized that the program I use to display the pictures won’t separate pictures within a post – they all get lumped into one gallery. So when you view the pictures in the gallery, only look at the first three pictures if you don’t want to spoil the answer.

 

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The angle of the femur seemed odd on one of the hip x-rays and there appeared to be a linear lucency through the base of the femoral neck. The radiologist thought that the lucency was just shadows, but we had the advantage of being able to examine the patient. Since he couldn’t bear weight on that leg and since he had pain when his leg was log-rolled, we had a suspicion that there was something more than a bruise or a strain going on. So we got a CT scan. The results are below.

Femoral neck fracture.

The radiologist called back and profusely thanked us for being diligent. It wasn’t like we could send the patient home unable to walk, so a CT scan wasn’t that much of a leap in testing.

The point of the post is NOT to bust on radiologists. This is a team sport, so we help each other out. They catch as many of our misses as we catch of theirs.

But a good physical exam can make you a lot more suspicious about equivocal x-ray findings.

Now here’s a good review article by Dr. Thomas Byrd about physical examination of the hip. Know this stuff and you’ll be ahead of the game.

3 comments

  1. Our Radiology group asks (but routinely doesn’t get or they ignore) for history on the requesition forms. This is the best they can do, since many times they are hundreds of miles away in dark rooms staring at computer screens.

    Bottom line is, if the report clinically doesn’t fit, get the next level test if you can BEFORE you send the patient out the door.

    Also, sometimes your support team tries to help by ordering plain films before you get into the room. Listen to the patient tell the story (if they can), understand the mechanism of injury, and examine all areas that were injured. Sometimes pain in one fracture masks the pain of other injuries, thus you miss the other, more subtle fractures that you didn’t pay attention to because “the x ray was of the hand and they didn’t complain about the wrist/forearm/elbow/shoulder etc.”

    I once examined a multiple kilogram-enhanced woman who slipped on wet linoleum. The trimalleolar fracture was obvious. The Ortho who came in asked about the other ankle, which I had ignored because of the obvious fracture, and I looked stupid when we got the contralateral ankle X ray which showed the bimalleolar fracture on that side.

    • Good advice.
      When someone comes in with an injury or a fall, I routinely examine the entire body, including moving all the joints in the unaffected arms and/or legs. Takes another minute to do and I can’t tell you how many unnoticed injuries I’ve found by doing so – especially in elderly patients.

  2. FYI: In a similar situation an MRI of the hip is a better test than a CT scan. It is easily possible that a non-displaced fracture won’t show up on the CT scan, but will be apparent on MRI. The orthopaedic rule of thumb is that if the patient has hip pain and is unable to walk there is a hip fracture unless you can prove that there isn’t. An MRI is the best test if the fracture is not apparent on the x-ray. Even with a non-displaced fracture the patient will usually hold the leg so that it looks short, flexed, and externally rotated. You can often make the diagnosis just looking at the position of the feet before you see the x-rays.

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