Diagnostic problems recommendations how to avoid mistakes and errors

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In certain cases problems may arise during the attempt to confirm or to exclude hip fractures in spite of a meticulous examination. Overlooking or recognizing too late a fracture may have serious consequences for the patient. The number of complaints rises steadily, sometimes leading to legal suits. It is for these reasons that we describe in detail instances where diagnostic problems may arise.

A hip fracture may be missed in polytrauma patients; their serious injuries may overshadow a femoral neck fracture causing no or very few symptoms. On account of the great impact of forces (being run over, collision, fall from great height) it is essential to take always a radiograph of the pelvis. If a hip dislocation, a femoral shaft fracture or bony/ligamentous injury of the knee (dashboard injury) have occurred at the same time, a radiograph of the femur in two planes has to be taken. The proximal and the distal epiphyses must be visible in their entirety (Fig. 96)!

Some patients with hip fractures do not localize their pain at the hip or groin but at the medial aspect of the thigh or even at the knee. If a meticulous clinical examination has not been performed and if radiographs were only taken of the distal femur and knee, a femoral neck fracture may be overlooked. This oversight has led to claims for compensation and even to a conviction of the physician.

The foremost risk of undisplaced fractures is the danger of misdiagnosing and overlooking the fracture (Williams et al, 1992; Pathak et al, 1997) (Fig. 97, see also Fig. 138).

It can also happen that a hip fracture is diagnosed erroneously in a patient with a history of injury and hip pain. Particularly in elderly persons, marginal osteophytes secondary to osteoarthritis or capsular calcifications may lead to a suspicion of a fracture as they project over the neck. This erroneous diagnosis may result in an unnecessary operation (Fig. 98). An indication for immediate surgery does not exist under these circum stances. There would have been enough time to confirm or exclude a fracture with additional examinations (internal and external rotation, magnifying films, comparison with the opposite hip and, if necessary, other imaging procedures).

L. Böhler taught for decades (first in 1951) and followed his own recommendations that in instances of suspected fractures three radiographs should always been taken (a.-p. films in external and

internal rotation and proper lateral radiographs) (Böhler, 1996). Even today it is advisable to follow his recommendations in problematic cases (Figs. 99 and 100).

It is possible that the diagnosis is made even when the patient is unable to recall neither the moment nor the fact of an injury. Also in this instance a radiograph of excellent quality will be useful to find out whether the fracture is fresh or remote. A high-riding trochanter, a marked shortening of the femoral neck and smooth fracture surfaces may point to a remote injury that might have happened even some weeks ago. The blood supply to the head fragment is preserved in some remote fractures. Months later a cortication of the proximal fracture surface is visible (Fig. 101).

Problems arise in determining the age of a healed or healing Garden-I fracture, when radiographs taken at the first examination show that the fracture is not fresh (Fig. 102).

The occurrence of several hip fractures after repeated falls is rare. In this scenario it is important to decide which of the fractures is fresh necessitating a stabilization (Fig. 103).

Attention should also be paid to fractures of the pubic ramus. As the accident mechanism is identical to hip fractures, the symptoms are similar. Often these patients are admitted to a hospital with the provisional diagnosis of a neck fracture. It may also happen that both fractures have occurred simultaneously creating a diagnostic dilemma (Fig. 104).

Finally, Fig. 105 illustrates an unfortunate but instructive example of the sequelae of an unrecognized neck fracture and its faulty treatment.

If a fracture is suspected, a diagnosis must be established. All pertinent examinations are mandatory. The aftercare of problematic and unrecognized fractures is the responsibility of an experienced specialist.

Hip Problems After Trauma Injury

Fig. 96. Missed femoral neck fracture in a polytraumatized patient due to inadequate radiographs.

This 19-year-old female patient was injured in a motorcycle accident having been a passenger. The clinical picture was dominated by shock, trauma to the chest wall and abdominal organs (ruptured spleen and liver) as well as by a compound, comminuted fracture of the right femoral diaphysis, patella and ankle. These injuries were treated immediately; a, b. The already on the a.-p. visible Garden-III neck fracture was missed due to inadequate radiographs; c. After the emergency treatment a multiorgan failure set in as well as an infection of the right femur. The leg was immobilized in extension; d. For this reason the internal fixation with two cancellous bone screws was only done 34 days later; e. 14 months later a MRI performed after screw removal showed a pie-shaped, partial necrosis of the head. The patient had to use crutches for 2 years; f. A repeated MRI after 5 years confirmed progressive healing of the necrosis; g. The contour of the femoral head was maintained. Since then the patient became a mother, she is free of symptoms

Fig. 96. Missed femoral neck fracture in a polytraumatized patient due to inadequate radiographs.

This 19-year-old female patient was injured in a motorcycle accident having been a passenger. The clinical picture was dominated by shock, trauma to the chest wall and abdominal organs (ruptured spleen and liver) as well as by a compound, comminuted fracture of the right femoral diaphysis, patella and ankle. These injuries were treated immediately; a, b. The already on the a.-p. visible Garden-III neck fracture was missed due to inadequate radiographs; c. After the emergency treatment a multiorgan failure set in as well as an infection of the right femur. The leg was immobilized in extension; d. For this reason the internal fixation with two cancellous bone screws was only done 34 days later; e. 14 months later a MRI performed after screw removal showed a pie-shaped, partial necrosis of the head. The patient had to use crutches for 2 years; f. A repeated MRI after 5 years confirmed progressive healing of the necrosis; g. The contour of the femoral head was maintained. Since then the patient became a mother, she is free of symptoms

Fig. 97. Unrecognized Garden-II neck fracture.

This 73-year-old female patient had a fall and banged her hip. a, b. On account of poorly exposed films in external rotation the injury was regarded as a contusion and the patient was discharged home. Subsequently, the patient was admitted to another hospital and while being mobilized her pain increased; c, d. A repeated radiograph revealed a Garden-III neck fracture

Fig. 98. False positive diagnosis.

The 83-year-old female patient injured her right hip during a fall; a, b. Diagnosis of the neck fracture was made; c. The patient was treated by an internal fixation with cannulated screws. On the radiograph no fracture could be seen. The examining physician had been induced into error by osteophytes caused be a coxarthrosis. (Trochanteric fractures occur more often than neck fractures in instances of advanced osteoarthritis)

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