We have had an interesting case over the past few weeks.
A person presented with foot pain of 2+ weeks.
They had presented at A&E on the day of the incident which led to injury, and had an x-ray which had shown no fracture.
2 weeks on, there had been little to no improvement but with all the clinical tell-tale signs of … a suspected fracture.
I am very fortunate to work in a multidisciplinary environment, and asked my esteemed colleague and podiatrist extraordinaire, Michelle Jones to get another opinion. I felt that this was important as ultimately the patient would have been in the middle of 2 differing opinions – a 3rd opinion hopefully would help clarify.
Michelle and I agreed; … a suspected fracture/stress response.
Now, fractures can be missed in emergency departments. This is not in any way a criticism, it is a fact and is due to a number of factors, including quick life-saving decisions being made, the severity and complexity of the injuries presenting, and the often unrealistic multiple concurrent tasks and the multidisciplinary approach expected. To repeat, we never criticise these cases.
To compound this (no pun intended), many fractures are visible on only a single x-ray view, and if that view is not obtained, then the examination will be interpreted as falsely negative – i.e no fracture found, even if there is one.
So, my young padawans, should we seek re-scanning?
Another complicating issue here is that the person in pain competes at elite level, and has the World Championships in 4 weeks.
Does this affect your opinion? Should this affect opinion?
Should we re-scan?
Bare in mind, stress-fractures are commonly clinical diagnosis, meaning scanning isn’t a necessity.
If the scan comes back positive for a fracture, treatment, approach and recovery stays the same.
If the scan comes back negative for a fracture, treatment, approach and recovery stays the same because of the clinical signs and symptoms.
Patient led, they did manage to get re-scanned, as they felt that clarity would help – if nothing else than from a psychological point of view; it’s (literally) black and white!
Or so it could be assumed.
The second x-ray was also negative; no fracture shown! (except perhaps evidence of a shadow – a healed fracture)
Now this raises an interesting point which I speak about in clinic whenever scanning is mentioned, considered, or sought.
There are 3 potential outcomes when someone seeks scanning;
- There is nothing wrong with you – thanks for coming!
- The explained working diagnosis (in this case a potential bony injury) has occurred, and we are simply confirming that we approaching recovery in the correct manner.
- There is a LOT going on here, and you need immediate and/or excessive treatment.
Bizarrely, the first one can be the most frustrating for someone in such pain; despite showing not a lot – which is actually the best result – this can be the hardest result to receive, because …
…“why am I in such pain, then?!”.
Human brains like straight-forward cause-effect answers.
“I am in pain because of that red dot on that scan”.
Unfortunately, this is not always what scans do. They are an image which captures a (static) moment in time, which is not always the same as a human in pain.
The frustration here was short-lived, as the next day, they had a phone call; it was fractured.
Fast forward a week, they had another phone call; it was not fractured.
Multiple radiologists and doctors had by now seen the scans, and can not agree on the status of the fracture. As above, these things are complex.
So how do we approach treatment and rehab?
Put simply, we act it as if it’s a fracture, and following the best available advice and guidance, they are expected to heal in the timelines expected of these types of injury.
Is there a point to this blog? If there is, it is that scanning absolutely can help.
In some cases, it is an absolute necessity.
But, blimey, it can also be incredibly complicated, and doesn’t always offer the clarity you may think.
(as an aside, x-rays should never be offered as routine, or sales tactics – read here; The clinical utility of routine spinal radiographs by chiropractors: a rapid review of the literature | Chiropractic & Manual Therapies | Full Text (biomedcentral.com) )
So if you come across a therapist that may seem like they are putting barriers up when it comes to scanning, it may be because of some of the above.
Well done for reading all of that; here is some more reading for you:
Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department, Pinto et al., 2018