Emergency Department Evaluation And Differential Diagnosis

The importance of a careful history and physical examination cannot be overstated. Orthopedic diagnosis is sometimes thought of as being as simple as taking an x-ray where the patient says the pain is. This philosophy is probably responsible more than any other factor for physicians' missing significant injuries.

Although x-ray is of course an important adjunct, it is not the ultimate diagnostic resource, for the following reasons. The pain of a fracture or even a dislocation may be referred to another area. For example, patients with disruption of the sternoclavicular joint or fracture of the humeral shaft may present complaining of shoulder pain. If the x-ray is based solely on where the patient reports subjective discomfort, then the injury might not even be included on the film. The area x-rayed should be determined not only by the patient's chief complaint, but also by systematic palpation, looking for subtle deformity or significant point tenderness.

Some fractures or dislocations are apparent only on special x-ray views, which are not part of the standard series for that body part. Such special views will never be ordered unless the physician has already formulated a presumptive differential diagnosis before x-ray, based on the history and physical findings.

Some injuries may not be radiologically apparent on the first day regardless of what views are taken. Common examples of such injuries are fracture of the scaphoid (carpal navicular), nondisplaced fracture of the radial head, and stress fracture of a metatarsal. The classic radiologic signs accompanying such injuries, such as the fat-pad sign of the elbow, are not always conveniently present, but suggestive history and findings commonly are. In such cases, the diagnosis of fracture may have to be purely clinical until 7 to 10 days after injury, when enough bony resorption has occurred at the fracture site to reveal a lucency on x-ray. A bone scan may suggest the fracture even sooner, but on the day of injury, there may be no readily available test capable of demonstrating the pathology. Only the physician's clinical impression, arrived at through a systematic history and physical examination, will result in proper and timely treatment of a radiologically undemonstrable fracture.

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