Example cases

A missed lis franc injury

A 30yr lady came into the emergency department at 3am whilst intoxicated following having her foot being run over by a taxi whilst she was exiting it. The patient was complaining of pain in her foot and ankle, both of which were not swollen, and she was weight bearing. The Images were reviewed by the A&E and discharged with no follow up. The patient represented with more pain and swelling. A subsequent X ray was performed showed to have a lis franc injury. The patient then underwent a CT scan which demonstrated the injury in a 3D model. Following this the patient underwent an orthopaedic procedure to correct the defect. The patient was seen again in fracture clinic 4 weeks post op and recovered well.

Learning point:

Lis franc fractures, are rare however potentially debilitating injury, all foot and ankle injuries should be examined clinically for tenderness in the dorsal forefoot, and if necessary imaging should be requested and a specialist should be consulted if the requester is unsure on what to look for. Lis Franc injuries are especially common in those who have been run over, due to the force of the injury. Missed  Lis Franc injuries continue to be very costly to the NHS in terms of litigation.

Appendicitis Audit.

Introduction: CT is more and more being used to diagnose appendicitis, given its high sensitivity and specificity. The RCR states that 90% of all radiological diagnosis of appendicitis should be correct with regards to correlation to histology.

Method: 50 patient’s records were obtained retrospectively with regards who had a CT scan showing appendicitis. The patients were then followed up to see whether or not they underwent an operation to remove the appendix or not. Finally the histology was then obtained from the operation and correlated with the radiological findings.

Results:  Of the 50 patients, 48 of those underwent an appendectomy. Of the two who didn’t, one was treated with IV antibiotics due to the formation of an appendix mass and later had an interval appendectomy and the other self discharged and was lost to follow up. The remaining 48 underwent an operation. All 48 patients had a microscopic histology showing appendicitis. 44 of those had macroscopic signs of appendicitis and the other 4 appendices were injected. None of the histology were normal.

Conclusion: The audit showed that the radiology department were accurately diagnosing appendicitis on axial imaging. CT should not remove the need to diagnose appendicitis as it is still a clinical diagnosis, however CT can be used in cases where a diagnosis is still uncertain. Surgeons and other physicians should be aware of the radiation exposure that comes with a CT abdo-pelvis.

A missed scaphoid fracture.

A 42yr male presented to the emergency room the day after a night out having punched a wall following an argument. The patient was tender over the distal metacarpal over the fifth finger. A boxers fracture was diagnosed clinically and the patient was sent to radiology to have this confirmed. The X ray clearly demonstrated the injury and was discussed with the orthopaedic SHO who asked for him to be seen in fracture clinic in 2 weeks time. The patient was discharged accordingly. Whilst in fracture clinic the surgeon also noticed that the patient had tenderness over the anatomical snuff box and the patient was sent for dedicated Scaphoid views were requested. the x rays clearly showed a fracture and the patient was booked for theatre. The old images were re-reviewed and it was seen to have a fracture over the scaphoid.

Learning point:

Distracting injuries are very common. One should always examine the entire hand/joint/limb and look for other injuries. With regards to reviewing images the entire x ray should be examined and not just the clinical aspect. Scaphoid continue to be missed and can lead to serious disabilities.

Abdominal X-ray audit:

Introduction: Abdominal X-ray are widely requested in the emergency department, especially for potential surgical patients, however their use and value are somewhat limited. We have noticed a lot of request being made for these radiographs without proper clinical need. This is not only putting a burden on the department it is also an unnecessary amount of radiation on the patients.

Method: We looked at 50 abdominal film request and compared it to the iRefer guidelines to see whether or not they met them. The guidelines for AXR’s were limited and really only used for obstruction and perforation in the acute setting.

Results: the results were un surprising. 23 of the 50 requests were made without meeting the guidelines and as one would expect all of the 23 axr’s showed no pathology. Of the 27 which were requested only 7 showed the correct pathology which was placed on the request card.

Conclusion: More teaching is required for junior doctors with regards to appropriate scans and also to the reference to iREFER which can be an invaluable tool to help guide doctors to request the correct imaging modalities.