Commonly Missed Orthopaedic Injuries Part 1

Despite the sophistication of imaging and the thoroughness of a physician’s physical examination, some injuries remain difficult to diagnose. Obviously, it is imperative for the diagnosis to be made as soon as possible to yield the best possible results for patients.

Achilles Tendon Rupture (Figure 1)

The Achilles tendon is the tendon of the posterior leg which connects the calf to the heel bone. Achilles tendon ruptures are often missed because they can be misdiagnosed, often

Figure 1

as ankle sprains, peroneal injury, tibialis tendon injury, and calf and muscle strain. The presence of Achilles tendon rupture may be misleading because a patient may still be able to walk, flex the plantar muscle against resistance and lack pain. To correctly diagnose an Achilles tendon rupture, a physician should palpate the tendon along the entire length, perform a Thompson test and perform a Matles test. To confirm physical examination findings, MRI imaging is often utilized.


Posterior Shoulder Dislocation (Figure 2)

While posterior shoulder dislocations are relatively uncommon, they are frequently

Figure 2

missed and confused with rotator cuff injury or shoulder contusions. Patients may present with the affected arm in internal rotation and adduction and have limited external rotation at the shoulder. Anteroposterior (AP) radiographs often show a normal shoulder-axillary radiographs increase diagnostic accuracy. Posterior shoulder dislocations may be associated with lesser tuberosity fractures and humeral head defects. Missed diagnosis could lead to chronic posterior dislocation and degenerative shoulder disease.



Perilunate Dislocation

Figure 3


Perilunate dislocations are wrist injuries caused by enough force to tear the ligaments and displace the lunate (Figure 3). Physicians should look for median nerve injury. Early diagnosis can prevent long-term problems and complications. To avoid missing the diagnosis,



Vascular Injury with Knee Dislocation

Knee dislocations are emergencies that require urgent reduction – they run a high risk for neurovascular injury. Physicians should always check the distal pulse to rule out popliteal artery injury. The knee joint should be reduced first with the circulation assessed following. Patients with good distal pulse will need Doppler, while patients with diminished pulse need arteriograms. If the patient has no distal pulse, emergent exploration is needed for restoration of circulation and prophylactic fasciotomy.

Pneumothorax with Scapular Fracture (Figure 4)

Figure 4

The scapula is surrounded by strong muscles and requires a lot of force to be broken. If the scapula is fractured, the injury may be associated with pulmonary complications. Physicians should always check to rule out pneumothorax. It is best to admit and observe these patients, as complications may arise.


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