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EMS brings you a woman who fell down her stairs at home.  She is awake and alert, has no other apparent injuries, and complains of pain below her left knee.  EMS reports the patient had tried to get up, but was unable to bear weight on her L leg.  They have applied a short-leg splint.

On exam, she is otherwise all right head-to-toe except for the L leg.  There, you feel pain and crepitus just below the L knee.  There is no effusion in the left knee and no posterior fossa hematoma.  The foot has normal pulses and good perfusion.  Neurologic function is intact distally.  Vitals are P 115, BP 105/70, RR 20, sat 99% RA, ox3.

You order an IV, NPO, pain meds and ask for a portable AP and cross-table view of the L knee and L tib-fib region. 

What does it show?
 

 
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Two-second drill:
Proximal Tibia Fracture, not well seen on cross table view
 
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In this case, the fracture of the proximal tibia was not going to be missed because it was clinically obvious.  However, it does illustrates the classic adage of plain radiology:  “A single view is no view”.  In truth, a single portable X-ray in a sick patient often provides a wealth of clinical information very quickly.  In this case, however, the suspected fracture is very hard to see -- only on the companion AP view can the fracture be easily visualized. 

 
 
 
 
 
The danger for us is those fractures that are NOT clinically obvious, where the single-view X-ray is non-diagnostic.  So not every suspected hip fracture, proximal humerus or ankle fracture will be easy to see.  Trust your clinical judgement first -- and get more  X-rays, another opinion, or a CT scan.

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Dr. Dallara practices Emergency Medicine in Virginia and North Carolina, and directs the Emergency Medicine PREP Course. www.emprepcourse.com

 

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