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Following an MVA, your resident and attending agree that the films are negative. A look at how simple oversight can lead to glaring errors.  

altA 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.

After 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.

A short while later, the oncoming attending receives a call from the radiologist, who states “You might want to take another look at that X-ray....”

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.

altDon’t skip the physical
It’s 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.

Discussion
Sternal fractures 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.

Follow up
The patient was called back in. A 12-lead EKG and cardiac enzymes were ordered, which came back normal. A bedside
ultrasound and CT scan of the chest were performed which did not reveal any acute findings. Trauma services was notified and outpatient follow-up was arranged. The
patient was discharged home in stable condition.

References:
1. Roy-Shapira A, Levi I, Khoda J. Sternal fractures: a red flag or a red herring? J Trauma. 1994;37(1):59.
2. 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.

 

Comments   

# more to seeCharles Cusumano, PA-C DFAAPA 2013-08-24 09:53
given the limited size of the X-ray in this article, there appears to be aL sided rib fx and subcutaneous emphysema. I could be wrong but it's worth considering
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