69.2 X–rays for bony injuries

You are more likely to make a mistake because you don’t examine a patient than because you don’t x-ray him. Although all fractures should in theory be X-rayed, this may be unnecessary with some of them, and you may have no X-rays. If films are scarce, keep them for injuries which involve a patient’s joints, especially his elbows, hips or ankles. Always X-ray him if his symptoms seem to be worse than your present diagnosis suggests. A fracture is a three dimensional lesion, so you will need X–rays in two planes at right angles in order to visualise it. For most fractures take an AP (anteroposterior) and a lateral view. Even if there is a radiologist’s report, look at all films yourself, and if you are in doubt, compare them with views of the other side, if possible on the same film. This is especially important in young children.

Make sure the films include enough of the patient. For example, a film of his forearm may fail to show an injury of his wrist, so in all long bone fractures, X–ray the joints above and below the fracture. Don’t overlook a proximal injury, for example a fracture of the neck of the femur. It is a major error to treat a distal injury, and to fail to diagnose a proximal one.

If you are not sure if he has a fracture or not, ask him to come for another X–ray in 7 to 10 days time. If he does have a fracture you will see it more easily then. If his films are normal a week after the injury, the problem is not in his bones.

X–rays will not show you the position of his bones at the time of the accident. For example, an injury may have severely displaced the bones of the knee and torn its ligaments, after which they may have returned to their normal position. So a normal X–ray does not exclude a ligamentous injury.

Don’t take ’X–rays for X–rays sake’. Many fractures can be diagnosed without them. Colles, Port, Smith, Bennett, Monteggia and Maisonneuve all described their fractures before X–rays were invented. If your X-ray machine does not work, or your stock of film is almost exhausted, here is some help.

IF YOU DON’T HAVE X–RAYS make your diagnosis of a fracture or a dislocation on: (1) the violence of the injury, (2) the classical deformities of particular injuries, (3) tenderness over a subcutaneous bone (if this is absent a fracture is unlikely), (4) loss of function (a patient who can walk and bear weight normally is unlikely to have a serious injury).

The injuries which least need an X–ray include: (1) extension fractures of the wrist, (2) clavicle fractures, (3) many tibial fractures (you can detect angulation and rotation clinically), (4) greenstick fractures of the forearm in children.

The injuries which most need an X–ray include: (1) doubtful hip injuries, which might be a slipped epiphysis, or fracture of the femoral neck, (2) possible penetrating wounds of the skull in children by hoes or garden forks, (3) ankle injuries, (4) elbow injuries, and (5) any long bone fracture where there might be a dislocation at the upper end, (6) severe foot injuries where the patient cannot walk.