What should I do if I suspect a fracture?

Management of Suspected Fractures

When concerned for a fracture, you should obtain appropriate imaging, starting with radiographs of the affected area as the initial diagnostic test, followed by advanced imaging if radiographs are negative or inconclusive. 1

Initial Assessment and Imaging

First-Line Imaging

• Radiographs (X-rays) are the mainstay of initial imaging for suspected fractures 1
  • For foot injuries: Use Ottawa rules to determine need for imaging (99% sensitivity for foot fractures) 1
  • For spine injuries: Radiographs should cover the entire spine due to potential for multilevel fractures 1
  • For dental trauma: Radiographs help confirm fracture type and guide management 1

When Radiographs Are Negative or Inconclusive

If radiographs are negative but clinical suspicion remains high:

• MRI without contrast is usually appropriate as the next imaging study 1

  • Highest sensitivity for detecting occult fractures
  • Particularly important for suspected hip, pelvis, or sacrum fractures 1
  • Can detect associated soft tissue injuries and bone marrow edema 1

• CT scan is an alternative when:

  • Rapid imaging is needed (e.g., trauma patients) 1
  • Complex fracture patterns need evaluation 1
  • MRI is contraindicated or unavailable 1

Special Considerations

Pregnant Patients

• For suspected pelvic/sacral fractures: MRI without contrast is the initial test of choice 1
• For long bone fractures: Start with radiographs, followed by MRI if needed 1
• Reassuringly, radiographs and CT scans not involving abdomen/pelvis have fetal absorbed dose <1 mGy 1

High-Risk Fractures

• Hip fractures: Require urgent evaluation with MRI if radiographs are negative 2

  • Associated with significant morbidity and mortality
  • Early surgical intervention typically needed

• Spine fractures:

  • Entire spine should be imaged due to risk of multilevel fractures 1
  • CT and MRI have complementary diagnostic utility 1

• Dental fractures:

  • Primary tooth with complicated fracture requires immediate dental referral 1
  • Avulsed primary teeth should not be replanted 1

Pitfalls to Avoid

1. Relying solely on radiographs when clinical suspicion is high - negative radiographs don't rule out fracture
2. Failing to consider stress fractures in patients with persistent pain but negative initial radiographs
3. Missing secondary fractures - particularly in spine injuries where multiple levels may be affected
4. Overlooking complications such as compartment syndrome or fat embolism syndrome in patients with long bone fractures 3
5. Neglecting to assess fall risk in elderly patients with fractures to prevent future injuries 2

By following this evidence-based approach to suspected fractures, you can ensure appropriate diagnosis and management while minimizing unnecessary radiation exposure and optimizing patient outcomes.