Fracture Screening Practice Questions

As a follow-up to our last episode, today we look at a few sample cases and practice questions related to fracture screening.

Chapters

• 0:21 Cervical Case 1
• 3:57 Cervical Case 2
• 7:37 Knee Case
• 10:24 Foot Case

Transcript

Introduction

Hello, and thanks for tuning in. Today we’re following up our fracture screening episode with a few practice cases. Let’s not waste time and jump right in.

Cervical Case 1

An 18-year-old patient presents to PT with a chief complaint of neck pain following a collision while riding an ATV 3 days ago. The pain started about 4 hours after the collision and has been gradually getting worse. He has not seen any other providers except for a chiropractor who did not take any images. Pain is relieved by lying down and aggravated with any neck movements. The patient is currently ambulatory and is able to maintain a seated posture with mild neck pain. 

Which of the following actions would be most appropriate for the physical therapist take next?

A.       Assess upper and lower extremity sensation

B.       Assess upper and lower extremity reflexes

C.      Assess cervical ROM

D.      Refer for imaging

I will give you a second to think or rewind if you need to. [Pause]

Okay, the correct answer here is D. refer for imaging. Thinking through the Canadian C Spine Rules here, our first task is to decide if there are any high-risk factors that require immediate referral without any other assessment. The high-risk factors are age 65 or older, a dangerous mechanism of injury, or paresthesias in the extremities. The patient is 18, so we do not refer based on age alone. If the MOI wasn’t dangerous, then the correct answer would be to assess upper and lower extremity sensation. However, a dangerous mechanism is defined as: 

• A fall from at least 3 feet or 5 stairs

• An axial load to the head (like diving in a swimming pool)

• A high speed motor vehicle accident (>100 kmph or >62 mph) or rollover or ejection

• A bicycle collision, or

• A motorized recreational vehicle collision

This patient experienced an ATV accident, which is a motorized recreational vehicle. So we are going to go ahead and refer for imaging.

Now here is a follow-up question for the same case:

The therapist has decided to refer this patient for imaging. Which of the following types of imaging would be most sensitive for catching cervical spine fractures?

A.       Radiography

B.       CT with contrast

C.      CT without contrast

D.      MRA

Take a second to decide.

The correct answer here is C., CT without contrast. Now, as we talked about last episode, these rules were designed for radiographs, are still very sensitive with radiographs, and a Cochrane meta-analysis concludes that the choice between radiographs and CTs will depend on many factors, including availability of resources and equipment. So we don’t think you should be afraid to choose radiographs if that’s the only option you have available. But if the question is asking about what is MOST SENSITIVE or what the American College of Radiology recommends, the current recommendation is for CT—without contrast— as the best initial imaging if the Canadian C Spine Rules or NEXUS criteria are positive.

Cervical Case 2

Let’s do one more neck case.

A 61-year-old patient presents to PT with head and neck pain 1 day after a motor vehicle accident. The patient was proceeding slowly through an intersection when another car ran a red light at about 55 miles per hour and struck the side of her vehicle. Her head and neck pain started immediately. She was taken to urgent care and given a cervical collar, but she does not recall if any images were taken. She denies any numbness or abnormal sensations in her upper or lower extremities. She is able to sit for about 30 minutes before the neck pain gets bad enough that she needs to lie down. She is currently ambulating with a single point cane, which she says, “Is just out of an abundance of caution.”

Which of the following actions would be MOST appropriate for the physical therapist to take next?

A.       Perform cervical distraction test

B.       Assess cervical sidebending AROM

C.      Assess cervical rotation AROM

D.      Refer for imaging

Take a moment to think or rewind, and then we’ll look at the answer. [Pause]

The correct answer here is C, assess cervical rotation AROM

 Let’s walk through the algorithm again. First are there any high-risk factors? The patient is 61, but the cutoff for high-risk is 65 or older. A dangerous mechanism for a vehicle accident would be a collision greater than 100 kmph or 62 mph, or if there was a rollover or an ejection. Although 55 mph is a pretty fast collision, it does not meet the criteria for high risk. The last high-risk factor we would look for is paresthesias in the extremies, which she denies.

So now that the high-risk criteria are clear, we start to look for any low-risk factor that would let us know it’s safe enough to assess cervical ROM. The low-risk factors are:

·      a simple rear-end MVC

·      patient in a sitting position in the ED

·      patient has been ambulatory at any time since the injury

·      delayed onset of neck pain, or

·      absence of midline c-spine tenderness

From the case, we know this is not a simple rear-end MVC because she was struck from the side. The case indicates that she is capable of sitting for 30 minutes at a time. We also know she has been ambulating with a cane. The onset of her neck pain was not delayed—it was immediate—and we do not know whether or not she has midline C-spine tenderness. So out of 5 low-risk factors, she appears to have two: sitting position and ambulation. She lacks to other factors—simple rear-end collision and delayed onset of pain—and we don’t know about the fifth. But remember that we only need ONE of these low-risk factors to move on and assess cervical ROM.

Since she can sit and walk, we now decide to assess cervical ROM. Specifically, we’re going to see if she has at least 45° rotation in both directions. If she has at least 45° rotation to one side but not the other, or if she does not have 45° to either side, then we would refer for radiographs or for CT.

Knee Case

Now let’s look at some lower extremity cases.

A 26-year-old graduate student was playing intramural soccer 5 days ago when her R knee buckled and twisted during a direction change and she fell. She was unable to put weight on it and had to be carried off the field. She saw the school’s athletic trainer, who gave her some crutches and recommend ice and NSAIDs for a week. When the patient presents to PT, she is able to walk four steps without the crutches but with a severe limp. Moderate swelling is visible around her anterior R knee, and she is tender on her patella, tibial tubercle, and joint line, but not on her fibular head. With the knee extended at rest, she lacks about 5° of extension.

Which of the following actions would be MOST appropriate for the physical therapist to take next?

A.       Refer for radiographs

B.       Perform Lachman’s test

C.      Perform McMurray’s test

D.      Assess knee flexion ROM

Think for a moment, and then we’ll continue.

Okay, got your answer? So in this case, we’re using the Ottawa knee rules to decide if it’s okay to continue examining this patient. This rule has five components. First, age over 55. Don’t forget about this one! Someone is going to forget to refer on the OCS (or in real life) because they forget to look at the age, or they get the cutoff confused with the Cervical Spine rule. But in this case, our patient is 26, so we are clear. Next, we’re looking for fibular head tenderness. In this case, that’s negative. Third, we’re looking for isolated bony tenderness of the patella. The patella is tender, but it’s not isolated—there is tibial tenderness too—so we’re clear there. Fourth, we’re looking for an INABILITY to take four steps BOTH immediately after the injury and in the office. Although the patient could not take four steps initially, she can now, so we’re clear there as well. (Remember that limping is okay—it does not invalidate the steps.) So far, we have no reason to refer for radiographs, so it’s looking like we are either going to perform Lachman’s, McMurray’s, or assess knee flexion. The last component of the Ottawa rule is one that is often forgotten: knee flexion ROM of at least 90°. So the correct answer here is D., assess knee flexion ROM. If we have less than 90°, we will be referring for radiographs. If we have at least 90°, then we can proceed with other assessments.

Foor/Ankle Case

Alright, one more case for you. A 67-year-old patient presents to PT the day after “rolling” his R ankle by accidentally stepping on the curb by his mailbox. He was able to stop himself from falling by using the mailbox for support. He reports that the inside of his foot caught the curb but the outside did not so that there was an inversion mechanism of injury. He had his son, who lives with him, bring out a transfer wheelchair they had in storage, and he has been using it since the injury. Assessment reveals slight swelling and a small area of ecchymosis on the lateral ankle. There is tenderness on the anterior aspect of the lateral malleolus, but there is no tenderness anywhere else on the foot or ankle.  When asked, he can stand up from the wheel chair and take four steps with pain and mild limping on the R foot.

Which of the following actions would be most appropriate for the therapist to take next?

A.       Refer for radiographs

B.       Perform the anterior drawer test

C.      Perform the Kleiger test

D.      Perform the reverse anterolateral drawer test

Pause, think about it, rewind if you want to, and make your choice.

Alright, so in this case, we’re using the Ottawa foot and ankle rule to see if we need to refer or if we can continue assessing. Unlike the other two rules, there is no automatic referral based on age in the Ottawa foot and ankle rule, so don’t let the patient’s age here trick you into a premature referral. If he, at 67-years-old, had also fallen and hit is head and had head or neck pain, then we’d be talking about an automatic referral for cervical imaging. But since it’s just his ankle, we don’t need to worry about age. Next we’re looking for tenderness in specific spots. We’re checking the base of the 5th metatarsal, the navicular, and the posterior edge and inferior tip of the distal 6 cm of both malleoli. In this case, the anterior edge of the lateral malleolus was tender, but that is not an Ottawa finding—that’s just normal ankle sprain tenderness. Once we have cleared tenderness, we are looking to see if the patient was unable to take four steps both immediately after the injury and when the patient presents to you. If the patient can take four steps at EITHER time, then that Ottawa criteria is negative. Here, the patient seems to have avoided walking immediately after the injury, but he can take four steps in your office. So the rules for this patient are negative.

At this point, we now have to decide which special test is most appropriate for the patient. It looks like a lateral ankle sprain, and the anterior drawer test is not the worst choice, but its sensitivity is pretty low, so our Clinical Practice Guideline recommends another test instead. The next option was the Kleiger test, which is also called the DF/ER test, and it’s used to check for high ankle sprains, so it would not be the best choice here. The last choice, reverse anterolateral drawer test, is the best option here, and it’s what our clinical practice guideline recommends because it has better sensitivity and similar specificity to the anterior drawer test.

Conclusion

I hope going through these cases has helped reinforce how you might use these imaging prediction rules in the clinic and how they might show up on the OCS exam. If you are working in an advanced practice setting or if your state allows you to order imaging, I want to give one more shoutout to the American College of Radiology Appropriateness Criteria. If you are uncertain what imaging options might be best for your patient, the Appropriateness Criteria is a really great resource to help guide you.

That’s it for today. Until next time, good luck, and study hard.