When an xray isn’t enough

Thursday, February 1, 2007

It seems so easy. You hurt something, wander into your closest ER, they take an xray and you know if you’ve broken a bone. Sometimes reality doesn’t meet expectation and a couple of injuries on the field today are good examples of the limitations of medicine.

Cleveland Brown’s Charlie Frye hurt his wrist against the Chiefs and will need further testing to find out if it’s broken. So why isn’t an xray good enough? It is only because our bodies are pretty good at hiding some injuries. There is a bone at the base of the thumb called the scaphoid (or just to be confusing, also called the navicular) which can be broken but may not show evidence of a break on normal xray pictures. If there is tenderness and swelling in the area, the intial treatment is splinting or casting with xrays retaken in 7-10 days. At that time, evidence of bone healing can be seen and the diagnosis can be confirmed. In an elite athlete though, one might see the testing process moved ahead a little quicker with a CT scan. You would know the answer right away, but even if there was no break, it wouldn’t help he quarterback hold the ball any tighter. And for “regular” folk, keeping an injutry immobilized is appropriate to promote healing.

By the way, I’m always amazed when I’m looking after patients and tell them that they have a broken bone, that they express relief that it wasn’t fractured. I know it’s obvious to me, but fracture, break and crack all mean the same thing.

Neck injuries are much more frightening and that much harder to make certain that no potential devastating injury exists. The bones and ligaments in the neck (the cervical spine) are there to protect the spinal cord and its function. When an athlete is hurt on the field or someone is hurt in a car wreck, there is always fear of missing a neck injury that will leave the person paralyzed.

In the ER, when a patient comes in from a car accident, often a hard collar is put on to protect the neck, presuming that it is broken until proven otherwise. Al Wilson had the same precautions when taken from the Bronco-Seahawk game. Plain xrays aren’t necessarily good enough to look at the bones; a CT scan is much better. But a CT scan isn’t good enough to look at the ligaments that hold the bones together. For that you need an MRI; but MRIs aren’t readily available everywhere and it’s probably overkill to get all those tests on every patient. Fortunately, physical exam and some common sense are good at ruling out most injury risk, however, when tests are needed, the technology exists to make certain that the spinal cord isn’t at risk.

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