To X-ray or not to X-ray – that is the question, but what is the answer?

Guidelines and protocols are in place for a reason. Based on years and years of experience and collated data and individual opinions of specialists etc, these guidelines are set up to aid the budding EM physician. They are not absolute though, as I learnt the hard way (a most unenjoyable way to learn!)

56 year old female, otherwise fit and well, comes in to ED one fine morning around 7am. I was part of the night team, counting the minutes down to when the day team will arrive and I will be able to go home. I was asked by the registrar to see this patient who had turned up to be assessed in the first assessment bay; she was at that time the only patient waiting to be seen (a rare occurrence in ED). I went into the makeshift cubicle (which basically meant drew the curtains around myself and the patient’s bed) introduced myself and asked her what brought her to ED that morning. She reported she had an ongoing pain in her left ankle, that she had been to her GP for. Twice. When I asked her when it first began, I was quite disappointed to find out this had been going on for a few weeks (3 I think she said!) She had been to her GP who had told her on two separate occasions that this seemed like soft tissue injury, and she was advised pain killers. She came in today because she felt she was not improving. She was into hiking and jogging and was a very fit 60 year old. The concern for her was she was unable to pursue her rigorous exercise routines due to this pain. She denied any direct trauma to the affected limb, and reported no swelling or bruising. No previous history of any joint problems (no prior medical history, actually!) and she examined very well: no bony tenderness to medial or lateral malleolus (the inner and outer parts of the ankle); she was able to put weight on it, as evidenced by the fact that she had walked into the department of her own accord without any support (and without a limp!); she had full range of motion except some difficulty in everting her foot, which reproduced the pain. There were no wounds or bruises or swellings, and full power and normal reflexes ended my examination, along with palpable pulses, good capillary refill distally and no neurological deficit. I advised her to continue taking pain relief and to seek a physiotherapist because she may have injured her muscles or a tendon/ligament and may require some specific exercises. She then suggested I x-ray it, and I explained to her why I thought it didn’t warrant an x-ray. She seemed a little less convinced but did not argue, and I sent her home. I documented everything, and thought that was the end of that.

I was called by one of my consultants a few days or weeks later, informing me that I had had a letter of complaint against me. It transpired that eventually when the pain had not gotten better over the next 10 days, despite having been seen by physiotherapy as well, the patient went private and got an x-ray done, which revealed (or so I am told) a stress fracture of the distal end of the fibula! A stress fracture! Of the fibula! The fibula is one of two long bones forming the lower part of your leg. I had never actually in my not-so-many-years of experience heard of a stress fracture involving the fibula.

My consultant was very supportive about it. She had gone through my documentation, and was quite satisfied with the plan I had made for the patient based on my assessment at that time. She agreed that based on that assessment there was no indication for the x-ray. But she taught me a few things about stress fractures that I did not know; that they are more common in the metatarsals than in the fibular end, but that in view of her age, I should have considered the possibility that she might have been osteoporotic and would be prone to fractures without any significant trauma, a detail that I had failed to factor in in my assessment of her. The experience taught me so much about how I need to remain humble in this profession that I decided to do a reflective note on it at the time and added it to my portfolio.

What have I learnt? I have a lower threshold for stress fractures in older patients, despite having no findings on examination/history suggestive of bony injury. I intend to read up on stress fractures and increase my knowledge base on the topic (and maybe blog about it in a later post!). I still intend to continue fully taking a history and doing a proper detailed examination of a patient, and then using my clinical judgement in order to decide on a plan of management for a patient.

You never know when your well-intentioned actions may be the wrong way to go, regardless of whether or not they work for the other hundreds of similar cases. So never get cocky, never get complacent, always be humble, and always, always DOCUMENT!

4 thoughts on “To X-ray or not to X-ray – that is the question, but what is the answer?”

  1. 3-4 months back my mum fell on her back and broke her left hip. Dr Amir Nabi Noor did an emergency hemiarthoplasty and she was recovering very well and was mobile with the use of frame. Then she fell again but this time on her right side, the pain was minimal as compared to the first time and since the fall was on the other side so I thought that everything was okay but by evening her pain level on the left side went up a notch so I took her to the ER of Shifa. Her left hip was X-rayed and the top of the femur was found severely fractured. Amir went in again and fixed it. I think in the elderdly one needs to be over cautious and do a full investigation on any fall.

    1. Sir thanks for sharing your personal experience! I totally agree with you, erring on the side of caution is the preferred way to go when dealing with advanced age group. Hope your mother is doing well now. Regards

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