an MVA, your resident and attending agree that the films are negative. A
look at how simple oversight can lead to glaring errors.
47-year-old male presents to your emergency room following a motor
vehicle accident. The second year resident gathers in the history that
he was a restrained front-seat passenger in a car that was traveling
approximately 45 mph when the car was rear-ended. Airbags were deployed
and the remainder of the passengers in his car were unharmed. His only
complaint was anterior chest wall pain, mostly in an area of
distribution that coincided with where his seatbelt would have been. But
he denied feeling short of breath, suffering loss of consciousness, or
having any abdominal pain. The resident reports that his vital signs and
physical exam is rather unremarkable. His initial vital signs showed a
room air oxygen saturation of 98%, heart rate of 87, respiratory rate of
18, BP of 128/87. On physical exam, the resident reports that the
patient had reproducible non-focal chest wall tenderness. He reports no
ecchymosis. The patient’s breath sounds were symmetric and clear to
auscultation bilaterally. He had no other significant findings.
the primary and secondary surveys were completed, a chest x-ray was
ordered to evaluate the cause of his chest pain. The EM resident review
of the chest x-ray was negative. Do you see anything? Further, the
over-read by a busy attending was read as negative as well. They agreed
with the plan to discharge home with oral analgesics.
while later, the oncoming attending receives a call from the
radiologist, who states “You might want to take another look at that
Get the whole story
The computer based x-ray
reading system used by the ED only shows thumbnails of the films not
currently displayed. The resident who ordered the film trusted his
memory that he only ordered a portable film while the x-ray tech shot a
PA and Lateral. Hence the resident wasn’t looking for and didn’t notice
that there were more views available. He saw what he expected to find
and nothing more.
Everyone makes mistakes from time to time. The
better clinician you are the less often you are expected to make those
simple errors. The resident was a talented and trusted clinician, so
the attending trusted that he would not commit such a simple mistake of
failing to look at all the films. It’s no slam on a clinician for an
attending to start at the beginning and make sure all the bases have
been covered. It may be tedious. But it shouldn’t be insulting.
Don’t skip the physical
hard to believe that a fractured sternum would not have point
tenderness, even crepitance. But it is easy to believe that a kind
resident would avoid hurting a patient ‘unnecessarily’ by identifying
the point of maximal pain by a thorough, but painful, palpation of the
entire chest wall. But it still should be done. The physical exam
should point the examiner to the areas of concern on the x-ray, not the
other way around.
should be in the differential diagnosis of any patient presenting with
blunt chest trauma. They usually result from a high-energy direct blow
to the anterior chest wall, typically seen when a driver’s chest strikes
the steering column. However, this is not always the case. In one
retrospective study of twenty-eight patients with sternal fractures, 79%
were wearing a seatbelt at the time1. The degree of displacement
correlates with the risk for associated thoracic injury2. Associated
injuries include rib fractures, pneumothorax, hemorthorax, pericardial
tamponade, pulmonary contusion, and blunt myocardial injury. An AP
radiograph of the chest has been shown to have a sensitivity of 50% for
detecting fractures of the sternum3, and the benefit of obtaining a
lateral view, while certainly helpful, has never really been quantified.
All patients should undergo a screening EKG and have a troponin level
checked; in a hemodynamically stable patient with unremarkable findings,
no further cardiac monitoring is indicated4. Patients with other
associated findings should undergo surgical consultation and
consideration for admission. Sternal fractures are relatively benign and
do not require any specific treatment3.
The patient was called back in. A 12-lead EKG and cardiac enzymes were ordered, which came back normal. A bedside
and CT scan of the chest were performed which did not reveal any acute
findings. Trauma services was notified and outpatient follow-up was
patient was discharged home in stable condition.
1. Roy-Shapira A, Levi I, Khoda J. Sternal fractures: a red flag or a red herring? J Trauma. 1994;37(1):59.
von Garrel T, Ince A, Junge A, Schnabel M, Bahrs C. The sternal
fracture: radiographic analysis of 200 fractures with special reference
to concomitant injuries. J Trauma. 2004;57(4):837.
3. Lederer W, Mair
D, Rabl W, Baubin M. Frequency of rib and sternum fracture associated
with out-of-hospital cardiopulmonary resuscitation is underestimated by
conventional chest X-ray. Resuscitation. 2004;60(2):157.
4. Peek GJ, Firmin RK. Isolated sternal fracture: an audit of 10 years’ experience. Injury. 1995;26(6)385.