The area x-rayed and the particular views ordered should be based on the history and physical examination, rather than simply on where the patient reports subjective pain. The joint above and the joint below a fracture should be included on the films because injury at the proximal or distal joint may coexist with long-bone fractures.
Injuries that may require special views to be visualized include acromioclavicular separation, fracture of the scaphoid, posterior shoulder dislocation, and sternoclavicular dislocation. That is why formulation of a presumptive diagnosis prior to x-ray is crucial. The physician may never order the specialized views needed to demonstrate a particular injury unless he or she has already anticipated the injury by virtue of the history and physical examination.
Children who have sustained trauma at or near a joint may need comparison studies of the opposite extremity to differentiate fracture lines from normal epiphyseal plates or ossifying growth centers. This is particularly true for the pediatric elbow, which typically exhibits six separate ossification centers sequentially as the child grows.
Although the physician may be tempted to base diagnostic and treatment decisions on the radiologist's written report, this is not advisable for at least two reasons. First, a report of negative findings does not rule out significant injury. Fractures of the radial head, scaphoid, or metatarsal shaft, for example, may initially be undetectable on x-ray, even when special views are taken. Second, the terminology used by radiologists to describe malposition of fracture fragments or disrupted joints is often different from the terminology used by orthopedists. Because the emergency physician will often be conferring with an orthopedist regarding the initial management of a patient, and because this interaction commonly involves describing the radiologic appearance of a patient's injury, it is important that the two physicians "speak the same language." This might not be achieved by simply relaying the radiologist's written description.
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