So a group of EM docs thought it would be fun to see how they compared to the orthopods in the diagnosis and treatment of distal fibular Salter Harris I fractures (SH-1) in a study titled: Consistency between emergency department and orthopedic physicians in the diagnosis and treatment of distal fibular Salter Harris I fractures.
They did retrospective chart review and assessed outcomes in children (N-247) who presented to a ED with distal fibular physis pain after trauma without evident fractures. Pts were included if they had open growth plates and normal 3-view ankle radiographs (read by an attending radiologist after d/c) and ortho f/u. With ortho’s dx considered the gold standard, EM docs were significantly more likely to diagnose SH-1 fx than were the orthopods (198 vs. 136 patients). 36 pts with ED diagnosis of SH-1 fractures were judged by ortho to have other fractures. In 19 pts (8%), fractures were found by ortho that were not identified during ED evaluation. All pts received ankle immobilization (splint, cast, or boot) before ED d/c. In summary, between 80-55% of patients with normal x- rays had a fracture. While this study has some flaws, it also has a very valuable take home point-
X-rays in kids are really hard to read. The corollary is that if an injured kid has a significantly tender joint, open growth plates, and negative x-rays, you should still immobilize ‘em and have them follow up in ortho clinic. -Chip
Pediatr Emerg Care 2011 Apr; 27:301