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Occult distal radial fractures
OCCULT DISTAL RADIAL FRACTURES J. DOCZI, G. SPRINGER, A. RENNER, and B. MARTSA
From the National Institute of Traumatology, Budapest, Hungary The radiological diagnosis of distal radial fractures is usually easy, but some fractures without displacement cannot be detected at the first examination. In this retrospective study of 626 wrist injuries diagnosed as "wrist sprain" we found 39 distal radial fractures which were discovered only after repeated examinations. The incidence of distal radial fractures was much higher than other wrist fractures that were diagnosed after repeated examinations. Repeat standard four-view X-ray examination, as well as other imaging methods, are necessary to diagnose these fractures.
Journal of Hand Surgery (British and European Volume, 1995) 20B: 5." 614-617 Occult fractures occur in the carpal bones (Hindman et al, 1989) and femoral neck (Rizzo et al, 1993) and the problematic age groups are children (Oudjhane et al, 1988) and elderly people (Berger et al, 1989). The wrist is one of the most frequently injured regions because people usually try to prevent a potentially more serious injury by extending the arms and hands during a fall. Fractures and injuries of the ligaments can occur in the wrist, depending on the energy and direction of the force, the position of the hand and the strength of the tissues. With conventional two-view X-ray examination almost all displaced fractures can be detected. Although primary diagnosis of carpal fractures without displacement can be difficult in many cases, distal radial fractures seldom cause such problem.
MATERIALS AND M E T H O D S At the National Institute of Traumatology, Budapest, we reviewed 2,978 patients with blunt trauma of the wrist in 1 year (1989). In one-quarter of the patients (626 cases) we could not detect a fracture on the first X-ray examination. These patients were treated as "wrist swain". We repeated the X-ray examination in 39% (245 cases). In most cases four-view pictures were taken, after removing the plaster splint, 8 to 12 (mean 9.6) days after the trauma. We found 36 distal radial fractures (and also six fractures of the scaphoid, three of the styloid process of the ulna and one of the triquetrum). Patients with negative radiological findings but wrists that were still swollen and tender were treated with immobilization for another week and then four-view radiographs were taken again. In these 14 patients, three distal radial fractures were diagnosed, and three more scaphoid fractures (Table 1). We found various types of distal radial fractures without displacement. Some typical cases are presented in Figures 1-4.
DISCUSSION Fig 1 Female, age 14. (a) No injury on the primary radiograph. (b) 9 days later subperiostaldistal radial metaphysealfracture can be seen.
Primary diagnosis of fractures without displacement and injuries of the epiphyses is often difficult, even for an 614
OCCULTDISTALRADIALFRACTURES
615
Table 1--Distal radial and other fractures diagnosed with 245 repeated examinations Distal radial
Styloid process 17 Distal end 14 Subperiosteal metaphyseal 6 Epiphyseal injury 2 Total 39
Other
Scaphoid Styloid process of the ulna Triquetrum
9 3 1 13
experienced radiologist. Fissures can be discovered only by orthograd X-rays (an X-ray in the same plane), which makes four-view radiographs necessary (B6hler et al, 1954). Marginal absorption in the hyperaemic phase following the fracture widens the fissures, making non-displaced fractures visible by 1 to 2 weeks (Russe, 1960). In an electron microscopic study, Thews and Fr6hlich (1987) found several parallel microfissures near the fracture and they explained the marginal resorption, which causes widening of the fracture site, by the fusion of these fissures. Yao and Lee (1988) explained the M R I findings of occult fractures by the changes in trabecular bone caused by microscopic compression fractures. An unrecognized and thus untreated fracture may bring not only legal consequences but the development of reflex sympathetic dystrophy which may result in long-term treatment and time lost from work. For this reason newer methods are used to diagnose a possible scaphoid fracture from bone isotope scan (Brismar, 1988) to M R I (Kettner and Pierre-Jerome, 1992), but special X-ray views (Daffner et al, 1992) and, especially, routine four-view radiographs give considerable help as well. In our material the number of distal radial fractures was four times that of occult scaphoid fractures and this is why they are important. The 39 distal radial fractures that were not diagnosed on first examination were one-sixth of the cases which were thought to be wrist sprains and studied by repeated radiographs. To put it another way, in this 1 year (1989) almost 2% of the 2241 distal radial fractures treated in our institute were discovered only by repeat examinations. After a negative primary X-ray examination a wrist injury can be considered to be a sprain only if repeated or additional examinations can exclude fracture or ligament injury safely. To engure this we believe that after blunt injury of the wrist, temporary immobilization and routine four-view radiographs 8 to 12 days later are obligatory. If the results are negative but the patient is still symptomatic, further investigations should be carried out to obtain an exact diagnosis.
Fig 2
Mate, age 13. (a) No injury on the primary radiograph. (b) Bilateral radiograph 8 days later; Salter type 1 epiphyseal injury of the distal end of the radius with minimaldisplacement (upper). The other, intact side (lower).
616
Fig 3
THE JOURNAL OF HAND SURGERY VOL. 20B No. 5 OCTOBER 1995
Female, age 79. (a) N o injury on the primary radiograph. (b) Four-view radiograph 10 days later; extra- and intraarticular fracture of the distal end of the radius.
617
OCCULT DISTAL RADIAL FRACTURES
References BERGER, P. E., OFSTEIN, R. A., JACKSON, D. W., MORRISON, D. S., SILVINO, N. and AMADOR, R. (1989). MRI demonstration of radiographically occult fractures: What have we been missing? Radiographics, 9: 3: 407-436. BI3HLER, L., TROJAN, E., and JAHMA, H. (1954). Die Behandlungergebnisse von 734 frischen Bfiichen des Kahnbeink6rpers der Hand. Wiederherstellungschirurgie und Traumatotogie, 2:86-111. BRISMAR, J. (1988). Skeletal scintigraphy of the wrist in suggested scaphoid fracture. Acta Radiologica, 29: 101-107. DAFFNER, R. H., EMMERLING, E. W. and BUTERBAUGH, G. A. (1992). Proximal and distal oblique radiography of the wrist: Value in occult injuries. Journal of Hand Surgery, 17A: 3: 499-503. HINDMAN, B. W., KULIK, W. J., LEE, G. and AVOLIO, R. E. (1989). Occult fractures of the carpals and metacarpals: demonstration by CT. American Journal of Roentgenology, 153: 3:529 532. KETTNER, N. W. and PIERRE-JEROME, C. (1992). Magnetic resonance imaging of the wrist: Occult osseous lesions. Journal of Manipulative and Physiological Therapy, 15: 9: 599-603. OUDJHANE, K., NEWMAN, B., OH, K. S., YOUNG, L. W. and GIRDANY, B. R. (1988). Occult fractures in preschool children. Journal of Trauma; 28: 6: 858-860. RIZZO, P. F., GOULD, E. S., LYDEN, J. P. and ASNIS, S. E. (1993). Diagnosis of occult fractures about the hip. Magnetic resonance imaging compared with bone-scanning. Journal of Bone and Joint Surgery, 75A: 3: 395-401. RUSSE, O. (1960). Fracture of the carpal navicular: Diagnosis, non-operative treatment and operative treatment. Journal of Bone and Joint Surgery, 42A: 5: 759-768. THEWS, A. und FROHLICH, P. (1987). Die submikroskopischen Sch~tdigungsmuster der Knochenkortikalis bei mechanischer Belastung. Der Unfallchirurg, 90: 233-240. YAO, L. and LEE, J. K. (1988). Occult intraosseous fracture: detection with MR imaging. Radiology, 167: 3: 749-751.
Accepted! 28 January 1995 Dr Ddezi Jdzsef, National Institute of Traumatology, H-1081 Budapest, Fiumei u. 17, Hungary. © 1995 The British Society for Surgery of the Hand
Fig 4
Female, age 24. (a) N o fracture o n the p r i m a r y r a d i o g r a p h , slight w i d e n i n g of the distal r a d i o - u l n a r j o i n t a n d d o r s a l tilt o f lunate. (b) 8 days later; transverse fracture o f the styloid process of the r a d i u s w i t h slight w i d e n i n g o f the s c a p h o - l u n a r gap.
From the National Institute of Traumatology, Budapest, Hungary The radiological diagnosis of distal radial fractures is usually easy, but some fractures without displacement cannot be detected at the first examination. In this retrospective study of 626 wrist injuries diagnosed as "wrist sprain" we found 39 distal radial fractures which were discovered only after repeated examinations. The incidence of distal radial fractures was much higher than other wrist fractures that were diagnosed after repeated examinations. Repeat standard four-view X-ray examination, as well as other imaging methods, are necessary to diagnose these fractures.
Journal of Hand Surgery (British and European Volume, 1995) 20B: 5." 614-617 Occult fractures occur in the carpal bones (Hindman et al, 1989) and femoral neck (Rizzo et al, 1993) and the problematic age groups are children (Oudjhane et al, 1988) and elderly people (Berger et al, 1989). The wrist is one of the most frequently injured regions because people usually try to prevent a potentially more serious injury by extending the arms and hands during a fall. Fractures and injuries of the ligaments can occur in the wrist, depending on the energy and direction of the force, the position of the hand and the strength of the tissues. With conventional two-view X-ray examination almost all displaced fractures can be detected. Although primary diagnosis of carpal fractures without displacement can be difficult in many cases, distal radial fractures seldom cause such problem.
MATERIALS AND M E T H O D S At the National Institute of Traumatology, Budapest, we reviewed 2,978 patients with blunt trauma of the wrist in 1 year (1989). In one-quarter of the patients (626 cases) we could not detect a fracture on the first X-ray examination. These patients were treated as "wrist swain". We repeated the X-ray examination in 39% (245 cases). In most cases four-view pictures were taken, after removing the plaster splint, 8 to 12 (mean 9.6) days after the trauma. We found 36 distal radial fractures (and also six fractures of the scaphoid, three of the styloid process of the ulna and one of the triquetrum). Patients with negative radiological findings but wrists that were still swollen and tender were treated with immobilization for another week and then four-view radiographs were taken again. In these 14 patients, three distal radial fractures were diagnosed, and three more scaphoid fractures (Table 1). We found various types of distal radial fractures without displacement. Some typical cases are presented in Figures 1-4.
DISCUSSION Fig 1 Female, age 14. (a) No injury on the primary radiograph. (b) 9 days later subperiostaldistal radial metaphysealfracture can be seen.
Primary diagnosis of fractures without displacement and injuries of the epiphyses is often difficult, even for an 614
OCCULTDISTALRADIALFRACTURES
615
Table 1--Distal radial and other fractures diagnosed with 245 repeated examinations Distal radial
Styloid process 17 Distal end 14 Subperiosteal metaphyseal 6 Epiphyseal injury 2 Total 39
Other
Scaphoid Styloid process of the ulna Triquetrum
9 3 1 13
experienced radiologist. Fissures can be discovered only by orthograd X-rays (an X-ray in the same plane), which makes four-view radiographs necessary (B6hler et al, 1954). Marginal absorption in the hyperaemic phase following the fracture widens the fissures, making non-displaced fractures visible by 1 to 2 weeks (Russe, 1960). In an electron microscopic study, Thews and Fr6hlich (1987) found several parallel microfissures near the fracture and they explained the marginal resorption, which causes widening of the fracture site, by the fusion of these fissures. Yao and Lee (1988) explained the M R I findings of occult fractures by the changes in trabecular bone caused by microscopic compression fractures. An unrecognized and thus untreated fracture may bring not only legal consequences but the development of reflex sympathetic dystrophy which may result in long-term treatment and time lost from work. For this reason newer methods are used to diagnose a possible scaphoid fracture from bone isotope scan (Brismar, 1988) to M R I (Kettner and Pierre-Jerome, 1992), but special X-ray views (Daffner et al, 1992) and, especially, routine four-view radiographs give considerable help as well. In our material the number of distal radial fractures was four times that of occult scaphoid fractures and this is why they are important. The 39 distal radial fractures that were not diagnosed on first examination were one-sixth of the cases which were thought to be wrist sprains and studied by repeated radiographs. To put it another way, in this 1 year (1989) almost 2% of the 2241 distal radial fractures treated in our institute were discovered only by repeat examinations. After a negative primary X-ray examination a wrist injury can be considered to be a sprain only if repeated or additional examinations can exclude fracture or ligament injury safely. To engure this we believe that after blunt injury of the wrist, temporary immobilization and routine four-view radiographs 8 to 12 days later are obligatory. If the results are negative but the patient is still symptomatic, further investigations should be carried out to obtain an exact diagnosis.
Fig 2
Mate, age 13. (a) No injury on the primary radiograph. (b) Bilateral radiograph 8 days later; Salter type 1 epiphyseal injury of the distal end of the radius with minimaldisplacement (upper). The other, intact side (lower).
616
Fig 3
THE JOURNAL OF HAND SURGERY VOL. 20B No. 5 OCTOBER 1995
Female, age 79. (a) N o injury on the primary radiograph. (b) Four-view radiograph 10 days later; extra- and intraarticular fracture of the distal end of the radius.
617
OCCULT DISTAL RADIAL FRACTURES
References BERGER, P. E., OFSTEIN, R. A., JACKSON, D. W., MORRISON, D. S., SILVINO, N. and AMADOR, R. (1989). MRI demonstration of radiographically occult fractures: What have we been missing? Radiographics, 9: 3: 407-436. BI3HLER, L., TROJAN, E., and JAHMA, H. (1954). Die Behandlungergebnisse von 734 frischen Bfiichen des Kahnbeink6rpers der Hand. Wiederherstellungschirurgie und Traumatotogie, 2:86-111. BRISMAR, J. (1988). Skeletal scintigraphy of the wrist in suggested scaphoid fracture. Acta Radiologica, 29: 101-107. DAFFNER, R. H., EMMERLING, E. W. and BUTERBAUGH, G. A. (1992). Proximal and distal oblique radiography of the wrist: Value in occult injuries. Journal of Hand Surgery, 17A: 3: 499-503. HINDMAN, B. W., KULIK, W. J., LEE, G. and AVOLIO, R. E. (1989). Occult fractures of the carpals and metacarpals: demonstration by CT. American Journal of Roentgenology, 153: 3:529 532. KETTNER, N. W. and PIERRE-JEROME, C. (1992). Magnetic resonance imaging of the wrist: Occult osseous lesions. Journal of Manipulative and Physiological Therapy, 15: 9: 599-603. OUDJHANE, K., NEWMAN, B., OH, K. S., YOUNG, L. W. and GIRDANY, B. R. (1988). Occult fractures in preschool children. Journal of Trauma; 28: 6: 858-860. RIZZO, P. F., GOULD, E. S., LYDEN, J. P. and ASNIS, S. E. (1993). Diagnosis of occult fractures about the hip. Magnetic resonance imaging compared with bone-scanning. Journal of Bone and Joint Surgery, 75A: 3: 395-401. RUSSE, O. (1960). Fracture of the carpal navicular: Diagnosis, non-operative treatment and operative treatment. Journal of Bone and Joint Surgery, 42A: 5: 759-768. THEWS, A. und FROHLICH, P. (1987). Die submikroskopischen Sch~tdigungsmuster der Knochenkortikalis bei mechanischer Belastung. Der Unfallchirurg, 90: 233-240. YAO, L. and LEE, J. K. (1988). Occult intraosseous fracture: detection with MR imaging. Radiology, 167: 3: 749-751.
Accepted! 28 January 1995 Dr Ddezi Jdzsef, National Institute of Traumatology, H-1081 Budapest, Fiumei u. 17, Hungary. © 1995 The British Society for Surgery of the Hand
Fig 4
Female, age 24. (a) N o fracture o n the p r i m a r y r a d i o g r a p h , slight w i d e n i n g of the distal r a d i o - u l n a r j o i n t a n d d o r s a l tilt o f lunate. (b) 8 days later; transverse fracture o f the styloid process of the r a d i u s w i t h slight w i d e n i n g o f the s c a p h o - l u n a r gap.