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Correlation between clinical and radiological diagnosis for fractures and dislocations in an accident department
Injury, 11,225-227
225
Printed in Great Britain
Correlation between clinical and radiological diagnosis for fractures and dislocations in an accident department W . J. M o r g a n , E. C. O g d e n , A. M a r t i n a n d L. S i n g h
Accident and Emergency Department, Western Infirmary, Glasgow Summary Clinicians and radiologists agreed on the presence or absenceof fracture or dislocation in 897 of 1011 cases (89 per cent). The agreement was closer in casesthat were thought on clinical grounds to show no injury. We think the high incidence of agreement in this group should help to reduce the number of radiographs used in an accident department. Further analysis of the results indicates which areas of the body have most missed fractures.
PATIENTS A N D M E T H O D S DURING one month the doctor seeing a suspected fracture or dislocation in the accident department ofthe Western Infirmary was asked: 1. Whether he thought the result of the radiological examination requested would be positive or negative. 2. How he would treat the patient if he did not know the radiological appearances. The patients studied were over 12 years of age and were all accident cases; medical and surgical diseases were not included. The doctors taking part in the survey comprised one senior registrar, three senior house officers and two preregistration house officers. All the radiographs were reported on by a radiologist and the doctor's clinical impression of the injury was compared with the radiological report. A total of 1011 radiographs were made. It is stressed that the purpose of the survey was not to see whether the doctor had been accurate about the presence of a fracture. In the accident department it is important for the doctor to recognize the possibility of bony injury and the necessity for radiological examination. Hence, the results
were analysed according to the site of the suspected fracture or dislocation (Tables I and I/) rather than by the particular injury. Tables III and I V show the sites of fractures in the limbs. Bones which were thought on clinical grounds to be unbroken but were shown by X-ray examination to have fractures ('missed fracture') made up an important group in which it was noted whether or not the radiological findings made a difference to treatment. RESULTS Of the 661 cases diagnosed on clinical grounds as having no fracture, only 40 (6 per cent) were shown by X-ray examination to have them (Table 1). In all, 350 cases were expected to show fractures and of these 74 (21 per cent) did not (Table II). The difference between the two figures is statistically significant (x2=52"09, P<0"0005). No unexpected fracture was found in 127 patients whose skulls were radiologically examined. The highest percentage of misdiagnosis was found by radiographs of the spine (18 per cent). Analysis of the 'clinically positive' injuries of the limbs shows that the best agreement between clinical and radiological findings occurred with fractures of the tibia and fibula (92 per cent), hip (92 per cent) and distal third of the forearm (90 per cent) (Tables III and IV). Of the 40 'clinically negative' patients with positive radiological findings, 25 had their treatment changed as a result of the findings. No fracture in this group required manipulation. However, one patient (with a fractured neck of the femur) required
226
Injury: the British Journal of Accident Surgery Vol. 11/No. 3
Table L Clinical findings which predicted a normal
Table I1. Clinical findings which predicted a positive
radiological appearance
radiological appearance
Site
Clinically negative
Radiologically positive
Site
Clinically positive
Radiologically negative
7 25
4 2
1
0
Skull Facial bones Dislocated temporomandibular joint
1
0
Spine
33
6
Ribs
14
7
Hand
73
8
Pelvis
4
0
Spine Hand
6 63
1 13
82 107 161 661
7 9 6 40
Skull Facial bones Ribs Sternum
Foot
Upper limb Lower limb Total
127 34
0
39
3 1
Pelvis Foot Upper limb Lower limb Total
3
1
44 103 84 350
9 19 18 74
Table III. Further analysis of clinically positive radiographs of the upper limbs
Site Distal third forearm Clavicle Neck of humerus Dislocated shoulder
Scaphoid Other Total
Clinically positive 49 9 14 10 7 14 103
Radiologically negative 5 2 6 1 2 3 19
operation and internal fixation (Table V). A total of 695 (70 per cent) of all the radiographs showed no abnormality. DISCUSSION
Contrasting results have been found in previous surveys comparing clinical and radiological diagnoses. Sutherland (1970) excluded normal radiographs from his results and found agreement in 33 per cent of cases. Other surveys have been largely of radiological examination of the gastrointestinal tract. Rawson (1965) found agreement in 90 per cent of cases examined radioiogically for upper gastrointestinal lesions. One would expect a high incidence of clinical and radiological agreement for fractures and dislocations, because most of these cause easily recognizable deformity. A figure of 70 per cent of normal radiographs is in keeping with the results of previous surveys. Cook (1966) found that out of 419 patients sent
Table IV. Further analysis of clinically positive radiographs of the lower limb Site Hip Malleolar Tibia and fibula Other Total
Clinically positive
Radiologically negative
25 32 13 14 84
2 10 1 5 18
by general practitioners for radiological examination of the limbs, 126 radiographs (30 per cent) were reported as positive. In the same survey a similar figure (25 per cent) was found for X-ray examinations of the chest. The fact that most diagnostic error was found with radiological examination of the spine is particularly important because of the serious complications associated with these fractures. Rogers (1957) stated that in 10 per cent of cases of fracture and dislocation of the cervical spine, evidence of damage or aggravation of damage to the cord developed during initial management. Clearly there is a risk of discharging a patient with a spinal fracture, because there are no abnormal physical signs. It is recommended that radiographs should be used whenever there is the slightest clinical suspicion of fracture or dislocation of the spine, but it must be remembered that the cord can be damaged in the absence of any bony injury.
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Morgan et al.: Clinical and Radiological Diagnosis
Table V. Analysis of 40 clinically negative cases which were radiologically positive
Site
Nasal bones Ribs Spine Lrbody CT-body T~2-body Coccyx Lumbar transverse processes Spinous process C7 Hand Metacarpals Proximal phalanx of thumb Little finger Foot Base of 5th metatarsal Toes Upper Limb Distal radius Neck of humerus Clavicle Head of radius Lateral epicondyle of humerus Scaphoid Lower Limb Malleoli
Tibia and fibula Neck of femur
Whether at the acute stage or later, the usefulness of radiographs of the skull is a matter of controversy. Bull and Zilkha (1968) concluded that they did not contribute materially to the diagnosis. Even if a fracture is present, there is no definite evidence that it is an important consideration in predicting the seriousness of a head injury. Indeed, Harwood-Nash et al. (1971) came to the conclusion that a fracture o f the skull is not synonymous with noteworthy intracranial injury; often it is only confirmatory evidence that a force was applied to the skull. One cannot ignore the fact that in this survey, when the doctor thought on clinical grounds that the skull would be normal, no case had a fracture. One of the dangers for the inexperienced casualty officer is that of discharging a patient considered to be clinically normal and having subsequent radiological examination reveal a fracture. Although most of these missed fractures are not very serious, the fact that a fracture
Cases (No.)
Change of treatment
3 1
No No
1 1 1
Admit. Rest and observation Collar splint Admit. Rest and observation
1
No
1 1
Admit Collar splint
3 3 2
Treatedin plaster No, but reviewed Strapping applied
5 2
Treated in plaster No
3 2 1 1 1 1
Treatedin plaster No, but reviewed No, but reviewed No, but reviewed Treated in plaster No, but reviewed
4 1 1
Treated in plaster Treated in above-knee plaster cast Required pin and plate fixation
has been missed is an understandable cause for complaint. The results of this survey must be an encouragement to the casualty officer to use his clinical judgement when requesting radiological examination.
REFERENCES
Bull W. B. and Zilkha K. J. (1968) Rationalising requests for X-ray films in neurology. Br. Med. J. 4, 569. Cook P. L. (1966) Experiences in the first year of an 'open door' X-ray department. Br. Med. J. 2, 351. Harwood-Nash C. E., Hendrick E. B. and Hudson A. R. ( 1971 ) The significance of skull fractures in children. Radiology 101, 151. Rawson M. D. (1965) Accuracy in diagnosis ofgastric and duodenal lesions. Lancet 1,698. Rogers W. A. (1957) Fractures and dislocations of the cervical spine. J. Bone Joint Surg. 39A, 341. Sutherland G. R. (1970) Agreement between clinical and radiological diagnosis. Br. Med. J. 4, 212.
Requests for reprints should be addressed to: Mr W. J. Morgan,Senior Registrar,Accidentand EmergencyDepartment, Western
Infirmary,Glasgow,G11 6NT, Scotland.
225
Printed in Great Britain
Correlation between clinical and radiological diagnosis for fractures and dislocations in an accident department W . J. M o r g a n , E. C. O g d e n , A. M a r t i n a n d L. S i n g h
Accident and Emergency Department, Western Infirmary, Glasgow Summary Clinicians and radiologists agreed on the presence or absenceof fracture or dislocation in 897 of 1011 cases (89 per cent). The agreement was closer in casesthat were thought on clinical grounds to show no injury. We think the high incidence of agreement in this group should help to reduce the number of radiographs used in an accident department. Further analysis of the results indicates which areas of the body have most missed fractures.
PATIENTS A N D M E T H O D S DURING one month the doctor seeing a suspected fracture or dislocation in the accident department ofthe Western Infirmary was asked: 1. Whether he thought the result of the radiological examination requested would be positive or negative. 2. How he would treat the patient if he did not know the radiological appearances. The patients studied were over 12 years of age and were all accident cases; medical and surgical diseases were not included. The doctors taking part in the survey comprised one senior registrar, three senior house officers and two preregistration house officers. All the radiographs were reported on by a radiologist and the doctor's clinical impression of the injury was compared with the radiological report. A total of 1011 radiographs were made. It is stressed that the purpose of the survey was not to see whether the doctor had been accurate about the presence of a fracture. In the accident department it is important for the doctor to recognize the possibility of bony injury and the necessity for radiological examination. Hence, the results
were analysed according to the site of the suspected fracture or dislocation (Tables I and I/) rather than by the particular injury. Tables III and I V show the sites of fractures in the limbs. Bones which were thought on clinical grounds to be unbroken but were shown by X-ray examination to have fractures ('missed fracture') made up an important group in which it was noted whether or not the radiological findings made a difference to treatment. RESULTS Of the 661 cases diagnosed on clinical grounds as having no fracture, only 40 (6 per cent) were shown by X-ray examination to have them (Table 1). In all, 350 cases were expected to show fractures and of these 74 (21 per cent) did not (Table II). The difference between the two figures is statistically significant (x2=52"09, P<0"0005). No unexpected fracture was found in 127 patients whose skulls were radiologically examined. The highest percentage of misdiagnosis was found by radiographs of the spine (18 per cent). Analysis of the 'clinically positive' injuries of the limbs shows that the best agreement between clinical and radiological findings occurred with fractures of the tibia and fibula (92 per cent), hip (92 per cent) and distal third of the forearm (90 per cent) (Tables III and IV). Of the 40 'clinically negative' patients with positive radiological findings, 25 had their treatment changed as a result of the findings. No fracture in this group required manipulation. However, one patient (with a fractured neck of the femur) required
226
Injury: the British Journal of Accident Surgery Vol. 11/No. 3
Table L Clinical findings which predicted a normal
Table I1. Clinical findings which predicted a positive
radiological appearance
radiological appearance
Site
Clinically negative
Radiologically positive
Site
Clinically positive
Radiologically negative
7 25
4 2
1
0
Skull Facial bones Dislocated temporomandibular joint
1
0
Spine
33
6
Ribs
14
7
Hand
73
8
Pelvis
4
0
Spine Hand
6 63
1 13
82 107 161 661
7 9 6 40
Skull Facial bones Ribs Sternum
Foot
Upper limb Lower limb Total
127 34
0
39
3 1
Pelvis Foot Upper limb Lower limb Total
3
1
44 103 84 350
9 19 18 74
Table III. Further analysis of clinically positive radiographs of the upper limbs
Site Distal third forearm Clavicle Neck of humerus Dislocated shoulder
Scaphoid Other Total
Clinically positive 49 9 14 10 7 14 103
Radiologically negative 5 2 6 1 2 3 19
operation and internal fixation (Table V). A total of 695 (70 per cent) of all the radiographs showed no abnormality. DISCUSSION
Contrasting results have been found in previous surveys comparing clinical and radiological diagnoses. Sutherland (1970) excluded normal radiographs from his results and found agreement in 33 per cent of cases. Other surveys have been largely of radiological examination of the gastrointestinal tract. Rawson (1965) found agreement in 90 per cent of cases examined radioiogically for upper gastrointestinal lesions. One would expect a high incidence of clinical and radiological agreement for fractures and dislocations, because most of these cause easily recognizable deformity. A figure of 70 per cent of normal radiographs is in keeping with the results of previous surveys. Cook (1966) found that out of 419 patients sent
Table IV. Further analysis of clinically positive radiographs of the lower limb Site Hip Malleolar Tibia and fibula Other Total
Clinically positive
Radiologically negative
25 32 13 14 84
2 10 1 5 18
by general practitioners for radiological examination of the limbs, 126 radiographs (30 per cent) were reported as positive. In the same survey a similar figure (25 per cent) was found for X-ray examinations of the chest. The fact that most diagnostic error was found with radiological examination of the spine is particularly important because of the serious complications associated with these fractures. Rogers (1957) stated that in 10 per cent of cases of fracture and dislocation of the cervical spine, evidence of damage or aggravation of damage to the cord developed during initial management. Clearly there is a risk of discharging a patient with a spinal fracture, because there are no abnormal physical signs. It is recommended that radiographs should be used whenever there is the slightest clinical suspicion of fracture or dislocation of the spine, but it must be remembered that the cord can be damaged in the absence of any bony injury.
227
Morgan et al.: Clinical and Radiological Diagnosis
Table V. Analysis of 40 clinically negative cases which were radiologically positive
Site
Nasal bones Ribs Spine Lrbody CT-body T~2-body Coccyx Lumbar transverse processes Spinous process C7 Hand Metacarpals Proximal phalanx of thumb Little finger Foot Base of 5th metatarsal Toes Upper Limb Distal radius Neck of humerus Clavicle Head of radius Lateral epicondyle of humerus Scaphoid Lower Limb Malleoli
Tibia and fibula Neck of femur
Whether at the acute stage or later, the usefulness of radiographs of the skull is a matter of controversy. Bull and Zilkha (1968) concluded that they did not contribute materially to the diagnosis. Even if a fracture is present, there is no definite evidence that it is an important consideration in predicting the seriousness of a head injury. Indeed, Harwood-Nash et al. (1971) came to the conclusion that a fracture o f the skull is not synonymous with noteworthy intracranial injury; often it is only confirmatory evidence that a force was applied to the skull. One cannot ignore the fact that in this survey, when the doctor thought on clinical grounds that the skull would be normal, no case had a fracture. One of the dangers for the inexperienced casualty officer is that of discharging a patient considered to be clinically normal and having subsequent radiological examination reveal a fracture. Although most of these missed fractures are not very serious, the fact that a fracture
Cases (No.)
Change of treatment
3 1
No No
1 1 1
Admit. Rest and observation Collar splint Admit. Rest and observation
1
No
1 1
Admit Collar splint
3 3 2
Treatedin plaster No, but reviewed Strapping applied
5 2
Treated in plaster No
3 2 1 1 1 1
Treatedin plaster No, but reviewed No, but reviewed No, but reviewed Treated in plaster No, but reviewed
4 1 1
Treated in plaster Treated in above-knee plaster cast Required pin and plate fixation
has been missed is an understandable cause for complaint. The results of this survey must be an encouragement to the casualty officer to use his clinical judgement when requesting radiological examination.
REFERENCES
Bull W. B. and Zilkha K. J. (1968) Rationalising requests for X-ray films in neurology. Br. Med. J. 4, 569. Cook P. L. (1966) Experiences in the first year of an 'open door' X-ray department. Br. Med. J. 2, 351. Harwood-Nash C. E., Hendrick E. B. and Hudson A. R. ( 1971 ) The significance of skull fractures in children. Radiology 101, 151. Rawson M. D. (1965) Accuracy in diagnosis ofgastric and duodenal lesions. Lancet 1,698. Rogers W. A. (1957) Fractures and dislocations of the cervical spine. J. Bone Joint Surg. 39A, 341. Sutherland G. R. (1970) Agreement between clinical and radiological diagnosis. Br. Med. J. 4, 212.
Requests for reprints should be addressed to: Mr W. J. Morgan,Senior Registrar,Accidentand EmergencyDepartment, Western
Infirmary,Glasgow,G11 6NT, Scotland.