Posigrad. med. J. (September 1967) 43, 568-573.

Commonly missed orthopaedic injuries

A. GRAHAM APLEYF.R.C.S.

Rowley Bristow Orthopaedic Hospital, Pyrford, Slurrey

CROSSING the road is safe enough-but only forthose who always take care. The child who relaxeshis vigilance is heading for disaster. The CasualtyOfficer is in a like condition. Most bone injuriesare obvious even to the patient and are easily con-firmed by the doctor; but without constant careerrors are inevitable and, as with crossing theroad, the penalty is high. The object of this shortarticle is to mark the Accident Black Spots: thoseareas where routine methods of examination mustbe amplified by a high index of suspicion. But firsta few guiding principles-The Casualty Officer'sHighway Code.Of course a careful history and thorough

clinical examination are essential in every case.This statement, constantly made, is true but full ofcliches and, therefore, ignored. The history reallydoes matter, and the doctor must listen patientlyas if he had all the time in the world. And when hebegins his clinical examination it is a mistake topounce on the injured part; assessment of thegeneral condition needs to come first; and thelocal examination which follows must be gentle,systematic and meticulous. Finally X-rays may beneeded for diagnostic precision or medico-legalprotection. With reasonable care and a strictroutine all the injuries described below can becorrectly diagnosed-and yet the long list of in-surance claims testifies to the frequency withwhich they are missed. The list is not complete-it never could be-but it contains the most per-sistent offenders.

The shoulder regionDislocations

Dislocations anywhere in the body are usuallyeasy to diagnose: the patient feels the joint go outof socket, he holds it immobile, and deformity isobvious. Anterior dislocation of the shoulder isalmost never missed (except perhaps in mentalpatients and epileptics) - in fact, the first-aidworker diagnoses it through a rugger jersey. Butposterior dislocation is much less obvious. Thedeformity may not be apparent unless bothshoulders are viewed from above (an unusual butuseful method of observation). Even the X-ray isnot unambiguous and is often reported as normal;

but some gleno-humeral incongruity is usuallyvisible and the humeral head is abnormal in shape-it often looks curiously like an electric lightbulb. The secret in doubtful cases is to demand alateral film; subluxation or dislocation is thenunmistakable (Fig. 1).

FIG. 1. Antero-posterior and lateral views of posteriordislocation of the shoulder.

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FracturesMost fractures of the neck of the humerus

present no diagnostic problem; but if the fractureis impacted it can be missed. The patient, often anelderly woman, has fallen and is reluctant to moveher shoulder; but with persuasion she can moveit, and because it is impacted no abnormal move-ment is detectable. The temptation is to dismiss theinjury as a sprain, and not to bother with X-rayfilms. What happens? A few days later the patientreturns with a reproachful look and an enormousbruise. Because the best treatment is active use,failure to diagnose the fracture is not necessarilyserious. Nevertheless ignorance is a poor founda-tion for treatment. The patient should be X-rayedand told that though the bone is 'cracked' shemust at all costs keep her shoulder moving. Thesling which she needs for comfort is not to beregarded as a badge signifying immobility but asthe starting point for increasingly vigorous use.

Torn supraspinatusThe supraspinatus tendon never tears unless it is

degenerate. But in most people aged over 45 yearsareas of degeneration are present, and a fall orlifting a heavy weight may tear the tendon near itsinsertion. The patient presents with a painfulstiffish shoulder. There may be a little tendernessjust below the tip of the acromion process but theX-ray is normal. Again, the condition is oftendiagnosed as a sprain, despite the fact that theshoulder joint is virtually incapable of beingsprained.The patient's subsequent fate depends upon

whether the tendon is partially or completely torn.Differentiation between these is easy: local anaes-thetic is injected into the tender area. With apartial tear active abduction is then possible, witha complete tear it is not: the attempt produces nomore than a useless shrug, although the arm canbe passively (and painlessly) lifted by the doctor.Providing the patient with a partial tear exercisesthe shoulder he will eventually recover, though theprocess may take many months. But if a completetear is missed (and the possibility of repair, there-fore, not considered) the situation is quitedifferent. Pain soon subsides; this fortifies thedoctor in his error, and he is liable to makereassuring promises of early recovery of power.Such optimism is unfounded. In the absence ofoperation (though this is by no means alwaysindicated) the weakness will be permanent.

The elbow and forearmFractured medial epicondyleMany elbow fractures need expert treatment,

but most are easy to diagnose. An important ex-

ception is fracture of the medial epicondylarepiphysis. When the epicondyle is merely avulsedfrom the humerus there is also no diagnosticproblem, especially if the normal elbow is X-rayedfor comparison (always a useful manoeuvre withepiphyseal injuries). Difficulty arises when theepicondyle is not merely avulsed, but is trappedinside the elbow joint. A child presents with aswollen elbow whose movements are considerablyrestricted, and an X-ray in which no fracture isobvious. But on careful inspection the films showthat the elbow joint harbours a 'loose body'-inreality the trapped epicondyle (Fig. 2). If other

FIG. 2. Antero-posterior and lateral views of trappedmedial epicondyle.

clues were lacking the diagnosis would be evenmore frequently missed. The two clues which alertthe doctor to scrutinize the films with exceptionalcare are: (1) the child, aged between 9 and 15years, has an elbow which is much stiffer thanwould be expected in the absence of bony damage,and (2) there is usually tingling or numbness alongthe distribution of the ulnar nerve. Any doubt isimmediately resolved by inspecting X-ray films ofboth elbows in comparable positions.

Fracture-dislocation of the forearmFracture of either the radius or the ulna is easy

to diagnose and usually easy to treat by closedmethods. But the diagnosis may be incomplete:the injury may be more than a fracture-it may bea fracture-dislocation. Unless the dual nature ofthe injury is recognized treatment is bound to fail.

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A. Graham Apley

Two distinct fracture-dislocations, each withItalian eponyms, form a spendidly matching pair.

(1) Monteggia: the upper ulna is fracturedand the superior radio-ulnar joint dislocated(Fig. 3).

(2) Galeazzi: the lower radius is fractured andthe inferior radio-ulnar joint dislocated (Fig. 4).

FIG. 3. Monteggia fracture-dislocation-the dislo-cation was originally missed because the elbow joint wasnot included in the film.

FIG. 4. Galeazzi fracture-dislocation.

Fracture-dislocation is a strong possibility if onlyone forearm bone is broken and is considerablyangulated-indeed, much angulation is otherwiseimpossible. But there is only one safe rule-neveraccept X-ray films of an injured forearm unlessthey include the entire length of the radius andulna.

The wristOnly two wrist injuries are diagnostically diffi-

cult, but between them they provide much gristfor the medico-legal mill.

Fractured scaphoidMost doctors are familiar with the patient who

hurts his wrist and whose X-ray shows an oldununited fracture of the scaphoid. With promptinghe recalls an injury many years previously whichhe or his doctor ignored, supposing it to be merelya sprain. He may even have been X-rayed but toldthere was no fracture.

Unfortunately the clinical signs of a fracturedscaphoid (pain on wrist dorsiflexion, tenderness inthe snuff box, and weakness of grip) can all bemimicked by a sprain; unfortunately it is notalways easy, unless the X-rays are of high quality,to detect a hair-line fracture in the scaphoid; andstill more unfortunately the symptoms usuallysubside, allaying suspicion.To avoid these mistakes there is only one safe

rule: the diagnosis of wrist sprain should neverbe accepted until a fracture has been excluded byadequate radiography. Antero-posterior andlateral views are not enough-the fracture mayshow only in oblique projections (Fig. 5). Even ifthese fail to show a fracture the patient should bere-examined 2 weeks later; if any abnormal signspersist further films are taken. Only if these showno fracture is it safe to assume that the wrist wasmerely sprained.Dislocated lunate

This is a puzzling diagnostic pitfall, becauseonce they are pointed out the signs are so obvious.Two features combine to mislead. First, the wristis too swollen for displacement to be clinicallyapparent; and second, there is usually no asso-ciated fracture. How many doctors can recall theprecise shape and relations of all eight carpalbones? and even the radiologist may nod. In fact,the X-rays are unmistakable. In the antero-posterior view the normal lunate has a roughlyquadrilateral appearance; the dislocated lunatelooks pointed and almost triangular. If the normalwrist also is X-rayed the difference is immediatelyobvious (Fig. 6). Lateral films not only confirmthe diagnosis but also differentiate a dislocatedlunate from a perilunar dislocation of the carpus.

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FIG. 5. The fractured scaphoid shows clearly only in the oblique film..Z<;. .: ........... : . . .... . . : ....... - ,. . . ...... ... ........ . E_ ,g.:., ... . . : .... . :: :.:. ':' .. s . : :., ,.e,._ .; ........... .. .... ...... ,.h _. :.::. 1& j .u . .......... ..- .0 .. ' ' ... ] E .. , . j | ...... ............| | B&.& ....... e e : . . | ...... @ s l ........ ......... .... s_ ! ^ .... :: .;.:. :.: . . * _ : i ;.-- . 3 | . . . .; :. i:. i.mx_ x , . x - - I E . :.::.: X g!_S':-: . . * _. - y. :.: '.S.s,§. t N .: ^ ....FIG. 6. Dislocated right lunate compared with the normal.

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A. Grahaun Apley

A presumptive diagnosis of dislocated lunatecan usually be made on clinical grounds. The dis-placed bone projects into the carpal tunnel, sothat median nerve tingling or numbness is com-mon and finger flexion is restricted. With thesesigns and X-ray films of both wrists the diagnosisshould never be missed.

The hip regionFractured neck of femurThe old lady who stumbles, falls and is then

unable to lift her leg almost certainly has fracturedthe neck of her femur; there is no diagnosticproblem (though frequently a geriatric one). Butif the fracture is impacted, she may well be ableto lift her leg and to walk. She may not even see adoctor, and if she does the paucity of signs isdeceptive. Unless the hip is X-rayed this injury isundiagnosable. Does missing it matter? It used tobe thought that these impacted fractures alwaysjoined without treatment-but this is not the case.A few days later some disimpact and then becomedisplaced. Treatment at this stage is more difficult.Consequently all hip injuries. however trivial,should be X-rayed and if there is an impactedfracture it should be fixed internally without delay.Almost the reverse problem is posed by the

patient with a story of hip injury, unable to lifther leg, but whose X-ray shows an intact femorlneck. If careful study of antero-posterior andlateral films rules out even the possibility of afractured neck, the ischio-pubic ramus should bescrutinized. The detection of a fracture in thisregion is a satisfying solution to the puzzle; andthe patient can be reassured that within a fewdays she should be able to walk perfectly well.

Slipped epiphysisWhereas a fractured neck of femur is only

occasionally overlooked, a slipped upper femoralepiphysis is regularly missed. In one publishedseries the average delay between onset of symp-toms and correct diagnosis was no less than 17weeks. The fat, undersexed, pre-pubertal child issuch an excellent candidate for this importantinjury, that, no matter how trivial the symptoms(and the only one may be an occasional ache inthe thigh or knee) X-ray films of the hips areessential. Of course if the leg is short, externallyrotated, and has limited abduction and internalrotation, there is no diagnostic difficulty. But inmost patients the slipping is gradual and in theearly stages the signs are minimal. The all-too-familiar story of a 'sprain' after running or jump-ing bedevils diagnosis, and the apparent recoverywhich follows invites procrastination. It is never

safe to diagnose a hip sprain which, like a shouldersprain, is very rare (if, indeed, either ever occurs).Any hip complaint in the pre-pubertal period, evenif the child's build is quite normal, demands X-ray.Even then the diagnosis is frequently missedbecause, in the early stages of slipped epiphysis(when it is easy to treat successfully) the changesin the antero-posterior X-ray are by no meansobvious. It is imperative not only to include bothhips on the film for comparison, but also to insistupon lateral views of both hips (Fig. 7). These aredevoid of ambiguity and only if they are insistedupon will the sad sequel of severe slipping beavoided.

FIG. 7. Antero-posterior and lateral views of slippedleft femoral epiphysis.

The kneeThe locked knee

Surprisingly enough the diagnosis of lockedknee is often missed. The fact that the knee hasbeen injured is obvious enough, but the vital pointthat it still is locked may pass unnoticed. Theexplanation is partly semantic and lies in themeaning of the word 'locked'. A locked door isfixed and immobile. A locked knee is not; it bendsfully (or almost fully) but lacks extension. More-over, it sometimes lacks only the last three or fourdegrees of extension. The normal knee can bestraightened fully with a convincing snap; evenslight loss of extension is easily recognized by thespringy elastic feeling when passive extension isattempted. The impression that something isjammed in the joint is quite accurate, because theusual cause is a torn meniscus jammed betweenfemur and tibia. The diagnosis can usually beconfirmed by localized tenderness over the jointline. It should not be supposed that because loss

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of extension is slight the diagnosis of locking ismere clinical pedantry. The knee must be un-locked; and if closed manipulation is inappro-priate or ineffective, operation is needed with theleast possible delay.

There are, of course, other causes of locking, sothat an X-ray is necessary. One condition whichmimics the torn meniscus is a fractured tibialspine; this is revealed by the X-ray but unlessspecifically sought for the abnormality can eludedetection.

Dislocated patellaWhile a patella is actually dislocated the diag-

nosis is manifest. The patient, usually a younggirl, falls to the ground quite unable to saveherself. As a rule the knee is considerably flexed;it is held quite immobile and looks the wrongshape. The patella lies on the lateral aspect of theknee. The prominence caused by the uncoveredmedial femoral condyle can mislead the observerinto supposing that the patella has dislocatedmedially.

Often, however, the dislocation reduces spon-taneously or with the help of a bystander. Thenthe true diagnosis may easily be missed. Thehistory that the patient could not save herself fromfalling should be sufficient to alert the doctor;confirmation is obtained by the 'apprehensiontest'. The patient's knee is flexed with one handwhile the patella is gently pushed laterally withthe other; if this manoeuvre causes the patientapprehension the test is positive. During the testthe patient recognizes the unpleasant sensation ofa patella about to displace and is naturally appre-hensive that dislocation may follow.

Ruptured tendo achillisThe weakness which in Achilles himself was

attributed to his having been held by the heel

while being dipped in the protecting waters, existsin all of us. The tendon is so thick that its centreis liable to be avascular; through the avasculararea rupture may occur, especially in people aged40 years or over. A favourite occasion is theFather's match at school. The patient is convincedthat he has been struck just above the heel andmay be aware that the tendon has ruptured. Butthe doctor may assure him that the rupture is onlypartial, or that only the plantaris tendon is torn.It is doubtful whether the tendo achillis evertears only partially, and even more doubtful if theplantaris can be torn; with the characteristichistory the patient has either torn the soleusmuscle in the mid-calf, or has completely rupturedthe tendo achillis just above the heel.Why is the diagnosis of complete tendon rupture

so often missed? The likely explanation is thatblood fills the gap between the ruptured ends,and the patient by using his long toe tendons isable (though weakly) to plantarflex the foot. Butthe gap about 1+ in. above the insertion canusually be palpated, and weakness of plantar-flexion always detected. Simmonds' test, however,establishes the diagnosis beyond doubt. Thepatient lies prone on a couch with both feet pro-truding'beyond its end. On the uninjured side thecalf is squeezed; this results in the foot plantar-flexing. When the calf on the affected side issqueezed no movement of the foot takes placebecause of the tendon rupture. The test alsodifferentiates a ruptured tendon from a tornsoleus. This muscle tears at its musculo-tendinousjunction causing tenderness in the thickest part ofthe calf; consequently squeezing the calf is dis-tinctly uncomfortable. Moreover, the gastro-cnemius is still intact, so the foot does plantarflexwhen the calf is squeezed. It is important todifferentiate the two conditions because a tornsoleus is treated conservatively whereas a rupturedtendo achillis needs operative repair.

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