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Radiographically Occult and Subtle Fractures: A Pictorial Review  [PDF]
Mohamed Jarraya,Daichi Hayashi,Frank W. Roemer,Michel D. Crema,Luis Diaz,Jane Conlin,Monica D. Marra,Nabil Jomaah,Ali Guermazi
Radiology Research and Practice , 2013, DOI: 10.1155/2013/370169
Abstract: Radiographically occult and subtle fractures are a diagnostic challenge. They may be divided into (1) “high energy trauma fracture,” (2) “fatigue fracture” from cyclical and sustained mechanical stress, and (3) “insufficiency fracture” occurring in weakened bone (e.g., in osteoporosis and postradiotherapy). Independently of the cause, the initial radiographic examination can be negative either because the findings seem normal or are too subtle. Early detection of these fractures is crucial to explain the patient’s symptoms and prevent further complications. Advanced imaging tools such as computed tomography, magnetic resonance imaging, and scintigraphy are highly valuable in this context. Our aim is to raise the awareness of radiologists and clinicians in these cases by presenting illustrative cases and a discussion of the relevant literature. 1. Introduction Radiographically occult and subtle fractures are a common diagnostic challenge in daily practice. Indeed, fractures represent up to 80% of the missed diagnoses in the emergency department [1]. Failure to recognize the subtle signs of osseous injury is one of the reasons behind this major diagnostic challenge [2]. While occult fractures present no radiographic findings, radiographically subtle fractures are easily overlooked on initial radiographs. In both cases, a negative radiographic diagnosis with prominent clinical suspicion of osseous injury will prompt advanced imaging examination such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, and nuclear medicine to confirm or exclude the clinically suspected diagnosis. The burden entailed in missing these fractures includes prolonged pain with a loss of function, and disability. Early detection, on the other hand, enables more effective treatment, a shorter hospitalization period if necessary, and decreased medical costs in the long run. It will also prevent inherent complications such as nonunion, malunion, premature osteoarthritis, and avascular osteonecrosis (as in scaphoid fracture) [3]. Occult and subtle fractures may be divided into: (1) fractures associated with high energy trauma; (2) fatigue fracture secondary to repetitive and unusual stress being applied to bone with normal elastic resistance; and (3) insufficiency fracture resulting from normal or minimal stress on a bone with decreased elastic resistance [4]. The term “stress fracture” is more general and encompasses both of the latter two entities [5]. Pediatric and microtrabecular fractures—known as bone bruises and contusions—are outside the scope of this
Clinical Value of the Ottawa Ankle Rules for Diagnosis of Fractures in Acute Ankle Injuries  [PDF]
Xin Wang, Shi-min Chang, Guang-rong Yu, Zhi-tao Rao
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0063228
Abstract: Background The Ottawa ankle rules (OAR) are clinical decision guidelines used to identify whether patients with ankle injuries need to undergo radiography. The OAR have been proven that their application reduces unnecessary radiography. They have nearly perfect sensitivity for identifying clinically significant ankle fractures. Objectives The purpose of this study was to assess the applicability of the OAR in China, to examine their accuracy for the diagnosis of fractures in patients with acute ankle sprains, and to assess their clinical utility for the detection of occult fractures. Methods In this prospective study, patients with acute ankle injuries were enrolled during a 6-month period. The eligible patients were examined by emergency orthopedic specialists using the OAR, and then underwent ankle radiography. The results of examination using the OAR were compared with the radiographic results to assess the accuracy of the OAR for ankle fractures. Patients with OAR results highly suggestive of fracture, but no evidence of a fracture on radiographs, were advised to undergo 3-dimensional computed tomography (3D-CT). Results 183 patients with ankle injuries were enrolled in the study and 63 of these injuries involved fractures. The pooled sensitivity, specificity, positive predictive value and negative predictive value of the OAR for detection of fractures of the ankle were 96.8%, 45.8%, 48.4% and 96.5%, respectively. Our results suggest that clinical application of the OAR could decrease unnecessary radiographs by 31.1%. Of the 21 patients with positive OAR results and negative radiographic findings who underwent 3D-CT examination, five had occult fractures of the lateral malleolus. Conclusions The OAR are applicable in the Chinese population, and have high sensitivity and modest specificity for the diagnosis of fractures associated with acute ankle injury. They may detect some occult fractures of the malleoli that are not visible on radiographs.
Ischiopubic and odontoid synchondrosis in a boy with progressive pseudorheumatoid chondrodysplasia
Ali Al Kaissi, Farid Ben Chehida, Maher Ben Ghachem, Franz Grill, Klaus Klaushofer
Pediatric Rheumatology , 2007, DOI: 10.1186/1546-0096-5-19
Abstract: Detailed clinical and radiological examinations were undertaken with emphasis on the usefulness of 3D-CT scanning.There was synchondrosis between the odontoid and the body of the axis and the cephalad part of the odontoid was detached. Bilateral ischiopubic ossification defects and ischiopubic and odontoid synchondroses were additional abnormalities. 3D-CT scan showed an orthotopic type of os odontoideum associated with an occult axial fracture.Children who are younger than seven years of age are predisposed to develop odontoid fracture. The latter occur because of the presence of physiological odontoid synchondrosis, but fractures can result from trivial injuries as well as from high-energy trauma. The persistence of an infantile odontoid, with a large pre-adulthood head in children with skeletal dysplasias, is a major risk factor for sudden death or significant morbidity. Comprehensive orthopaedic management must follow early identification of these malformations.Osteochondrodysplasias are a large heterogeneous group of genetic skeletal dysplasias. Skeletal dysplasias are diagnosed and classified by their clinical phenotype, radiographic features, and their genetic pattern of inheritance [1]Spranger et al. first described progressive pseudorheumatoid chondrodyspalsia (PPRC) as a progressive connective tissue disease, which combined the radiological features of Scheuermann's disease, with radiographic features of juvenile rheumatoid arthritis [1-3]. The disorder is classified as an autosomal, recessively inherited chondrodyspalsia, with absence of inflammatory parameters. Differentiating progressive pseudorheumatoid chondrodyspalsia (PPRC) from Juvenile rheumatoid arthritis (JRA) is important for Rheumatologists, radiologists and clinicians to further assess and estimate the prognosis and treatment of this generalised bone-cartilage dysplasia syndrome.In addition our patient had a divided odontoid process, in which the cephalad part was detached from its base, and
Combined pubic rami and sacral osteoporotic fractures: a prospective study
M. Alnaib,S. Waters,Y. Shanshal,N. Caplan,S. Jones,A. St Clair Gibson,D. Kader
Journal of Orthopaedics and Traumatology , 2012, DOI: 10.1007/s10195-012-0182-2
Abstract: The presence of low back pain and tenderness in patients who had low-impact pelvic injuries was highly suggestive of the presence of an associated SOF. There was a high association between sacral and PROFs. The length of stay of patients with PROFs associated with sacral osteoporotic fractures was significantly longer than that of patients with PROFs only. Therefore, we recommend considering the high association between SOFs and PROFs in planning the management and rehabilitation of patients with POFs.
Occult Fractures in the Carpal Region: Incidental Findings on Bone Scintigraphy  [PDF]
Sahel Zoakman, Roderick van Leerdam, Frank Beeres, Steven Rhemrev
Open Journal of Orthopedics (OJO) , 2013, DOI: 10.4236/ojo.2013.31007
Abstract: The aim of this study was to evaluate the number and distribution of fractures around the wrist found on bone scintigraphy in patients with a clinically suspected scaphoid fracture and negative initial radiographs. We retrospectively included 445 consecutive patients with a suspected scaphoid fracture who underwent routine bone scintigraphy. None of the radiographs showed evidence of a fracture. We analyzed the type and number of other fractures incidentally found on bone scintigraphy. On average, bone scintigraphy was done in 4 days (1 - 9). The outcome of bone scintigraphy: 80 (18.0%) a scaphoid fracture, 145 (32.6%) another fracture in the carpal region, 208 (46.7%) normal and the diagnosis of 12 (2.8%) was unclear. In the present study, we demonstrated that in patients with a clinically suspected scaphoid fracture and negative initial radiographs, bone scintigraphy detected in many cases (64.4%) other fractures in the carpal region. This suggests that radiographs not only miss scaphoid but also many other carpal and distal radius fractures. Solutions should be found to solve this problem and probably advanced imaging techniques like CT, MRI or bone scintigraphy should be used in the correct clinical scenario.
Current diagnosis of occult or cryptic hepatitis B
Jo?o Renato Rebello Pinho
Einstein (S?o Paulo) , 2005,
Abstract: The present article presents a kind of hepatitis B in patients whodo not have the surface antigen (HbsAg) detectable in sera. It hasbeen described in different parts of the world and is known todayas “occult or criptic hepatitis B” and its importance has beenextensively discussed in the edical literature. Biological aspectsof the disease, its natural history, etiology and pathogenesis aredescribed. Occult hepatitis B virus infection has been found amongpatients with hepatitis C, HIV infection, hepatitis non A-E andhepatocellular carcinoma. The persistence of replication of thehepatitis B virus after acute hepatitis reinforces the need forscreening blood donators with anti-HBc and emphasizes theimportance of adoption of tests to detect nucleic acids in order toavoid the transmission of hepatitis B from seronegative blooddonors.
Introducing a Clinical Practice Guideline Using Early CT in the Diagnosis of Scaphoid and Other Fractures  [cached]
Pincus, Steven,Weber, Merle,Meakin, Alex,Breadmore, Ross
Western Journal of Emergency Medicine : Integrating Emergency Care with Population Health , 2009,
Abstract: Objective: We developed and implemented clinical practice guideline (CPG) using computerized tomography (CT) as the initial imaging method in the emergency department management of scaphoid fractures. We hypothesized that this CPG would decrease unnecessary immobilization and lead to earlier return to work.Methods: This observational study evaluated implementation of our CPG, which incorporated early wrist CT in patients with “clinical scaphoid fracture”: a mechanism of injury consistent with scaphoid fracture, anatomical snuff box tenderness, and normal initial plain x-rays. Outcome measures were the final diagnosis as determined by orthopaedic review of the clinical and imaging data. Patient outcomes included time to return to work and patient satisfaction as determined by telephone interview at ten days.Results: Eighty patients completed the study protocol in a regional emergency department.In this patient population CT detected 28 fractures in 25 patients, including six scaphoid fractures, five triquetral fractures, four radius fractures, and 13 other related fractures. Fifty-three patients had normal CT. Eight of these patients had significant ongoing pain at follow up and had an MRI, with only two bone bruises identified. The patients with normal CTs avoided prolonged immobilization (mean time in plaster 2.7 days) and had no or minimal time off work (mean 1.6 days). Patient satisfaction was an average 4.2/5.Conclusion: This CPG resulted in rapid and accurate management of patients with suspected occult scaphoid injury, minimized unnecessary immobilization and was acceptable to patients.[WestJEM. 2009;10(4):227-232.]
Evaluation of accuracy of ultrasonography in the diagnosis of zygomatic arch fractures
Mozhdeh Mehdizadeh,Moein Hoseini-Shirazi,Forouzan Farahbod
Journal of Isfahan Dental School , 2011,
Abstract: Introduction: In recent years, computed tomography (CT) scan has become an alternative to conventional radiography; however, the use of ultrasound in detecting zygomatic arch fractures has been rarely evaluated. The aim of this study was to evaluate accuracy of ultrasonography in the diagnosis of zygomatic arch fractures.Materials and methods: Fifteen patients (9 men and 6 women) with clinical signs of midfacial fractures, whose CT scan findings showed unilateral zygomatic arch fracture, were selected. All the patients underwent bilateral ultrasound examinations. All the sonographic techniques were carried out and interpreted by the same sonologist who was not aware of the CT results. Data were analyzed to determine sensitivity and specificity of ultrasonography in the diagnosis of zygomatic arch fractures.Results: Ultrasound assessed the fractured arches with a sensitivity of 100% (15 of 15 patients, with no false negatives) and the un-fractured arches with a specificity of 100% (no false positives).Conclusion: Based on the results of the present study ultrasound is a useful diagnostic tool for zygomatic arch fractures in initial investigations, and can help reduce the total number of diagnostic radiographic procedures and overall radiation exposure.Key words: Diagnosis, Fracture, Ultrasonography, Zygomatic arch.
Vertebral Bone Drilling (Puncture) Attenuates the Intractable Pain Due to Vertebral Fractures without Collapse  [PDF]
Koichi Ota, Hirosi Nagai
Open Journal of Anesthesiology (OJAnes) , 2016, DOI: 10.4236/ojanes.2016.64012
Abstract: Purpose: Osteoporotic vertebral fractures with no sign of vertebral collapse on initial radiographs, which is so-called occult vertebral fractures (VFs), exist. Occult VFs have a high rate of missed diagnosis, and the treatment of these fractures has rarely been discussed in the literature. We evaluated the effects of vertebral bone drilling for the pain due to occults VFs. Materials and Methods: Eighteen patients with painful osteoporotic occult VFs underwent the vertebral bone drilling. We evaluated the clinical outcome by comparing numerical rating scale (NRS) and activity of daily life (ADL) values between before and after the vertebral bone drilling. Comparisons were made by using Wilcoxon signed rank test. Results: The mean baseline NRS and ADL score, and the mean NRS and ALD score after the bone drilling were 8.4 ± 0.8, 2.2 ± 0.6, 2.4 ± 1.0, 4.6 ± 0.5, respectively. Among the patients, we detected significant improvements in NRS pain score and ADL score after the drilling compared with baseline score (p < 0.0002). Conclusion: Vertebral bone drilling at the site of painful vertebral compression fractures alleviated the intractable pain due to osteoporotic occult VFs.
Type 4 capitellum fractures: Diagnosis and treatment strategies  [cached]
Suresh S
Indian Journal of Orthopaedics , 2009,
Abstract: Background: Fractures of the capitellum are rare injuries of the elbow usually seen in the adolescents. This fracture is often missed in the emergency room if a proper radiograph is not available. Recent reports have described many modalities of treatment favoring headless screw for fixation. The facility for headless screw fixation, however, is not available in most centers. This paper presents the diagnosis and management of type 4 capituller fractures (Mckee) with gadgets available in a district hospital. Materials and Methods: Between 2004 and 2007 three patients with right sided type IV capetullar fracture were treated in a district hospital. There were two boys aged 15 and 17 and one 33 years old lady. In one case, the fracture was missed in the emergency room. A double arc sign in the lateral views of the X-rays of the elbow was seen in all the cases. In each case a preoperative CT scan was done and a diagnosis of Mckee type IV fracture of the capitellum was made. Under tourniquet, using extended lateral approach, open reduction and internal fixation was done using 4mm partially threaded AO cancellous screws (n=2) and 2.7 mm AO screws (n=1), under vision from posterior to anterior direction from the posterior aspect of lateral condyle of humerus avoiding articular penetration. Results: All the fractures united uneventfully. At the end of one year follow-up, two cases had excellent elbow function; implants were removed and there were no signs of AVN or arthritis. The third case had good elbow ROM at 11 months without AVN. Conclusion: Double arc sign on lateral X-rays of the elbow along with pre-operative CT scan evaluation is important to avoid a missed diagnosis and analysis of type IV capitellur fracture. Fixation with non-cannulated ordinary AO screws using extended Kocher′s lateral approach has given good results.
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