M u s c u l o s k e l e t a l I m a g i n g • R ev i ew

Ha et al.
Pitfalls in Radiography of Lower Extremity Trauma

Musculoskeletal Imaging
Review FOCUS ON:

Radiographic Pitfalls in Lower

Extremity Trauma
Alice S. Ha1 OBJECTIVE. Radiography remains the imaging standard for fracture detection after
Jack A. Porrino trauma. However, fractures continue to be the most common type of missed injuries. In this
Felix S. Chew article, we describe common radiographic pitfalls in lower extremity trauma and describe
strategies for dealing with them.
Ha AS, Porrino JA, Chew FS CONCLUSION. Pitfalls include insufficient views, improperly positioned or technical-
ly imperfect radiographs, nondisplaced fractures, commonly missed locations, small avul-
sions portending large injury, sesamoid injuries, satisfaction of search, incomplete or faulty
American Journal of Roentgenology 2014.203:492-500.

reasoning, and periprosthetic fractures.

R
adiography remains the initial
modality to detect or exclude the
presence of a fracture. According
to the American Academy of Or-
thopaedic Surgeons [1], 7,310,000 physician
visits and 3,148,000 emergency department
visits were related to extremity fractures in
2003, leading to 867,000 hospitalizations. Pit-
falls for the radiologist that may result in a
missed or delayed diagnosis abound in this
circumstance. Failure to diagnose is the most
common error alleged in medical malpractice
suits against radiologists, and extremity frac-
tures are the second most frequently missed
diagnosis (after breast cancer) [2]. Although
some missed fractures may be related to per-
ceptual errors that appear to be avoidable in
retrospect, others are related to anatomic,
Keywords: fracture, lower extremity, pitfalls, technical, and physiologic factors that are out
radiography of the interpreting radiologist’s control. In a
recent study of 3081 confirmed fractures in
DOI:10.2214/AJR.14.12626
emergency department patients, 115 fractures
Received January 30, 2014; accepted after revision were initially missed [3]. Fifty-three percent
April 23, 2014. of missed fractures occurred in the lower ex-
1
tremities, with the foot being the most missed
All authors: Department of Radiology, University of
Washington, Box 354755, 4245 Roosevelt Way NE,
location. Postulated reasons for these errors
Seattle, WA 98105. Address correspondence to included subtle fractures (37%) and radio-
A. S. Ha (aha1@uw.edu). graphically occult fractures (33%). Leeper et
al. [4] showed that, of missed injuries at a lev-
AJR 2014; 203:492–500
el I trauma center (15%), 70% were fractures.
0361–803X/14/2033–492 In this article, we identify several common ra-
diographic pitfalls in lower extremity trauma
© American Roentgen Ray Society and describe strategies for dealing with them.
Pitfalls
Pitfall 1: Insufficient Views
Many fractures are visible on only a single
view. If that view is not obtained, then the ex-
amination will be interpreted as falsely nega-
tive. Most radiology departments follow pro-
tocols that call for orthogonal views in frontal
(anteroposterior or posteroanterior) and later-
al projections for the long bones. For the hip,
knee, ankle, and foot, various additional views
may also be obtained (Table 1). At the knee,
fractures of the patella may not be evident un-
less an axial patellar view is obtained (Fig. 1).
The lack of weight-bearing views can lead to
false-negative radiographic findings in Lis-
franc or Chopart joint injuries [5, 6]. Stress
views may be necessary to show injury to the
ankle mortise or syndesmotic diastasis. When
there is high clinical suspicion for a fracture de-
spite initial negative radiographic findings, ob-
taining extra radiographic views in an attempt
to identify a fracture may not be the most effi-
cient or cost-effective course [7–10]. Instead,
when available, CT or MRI may be a better op-
tion. MRI is better at identifying soft-tissue in-
juries that may have clinical importance.
Pitfall 2: Improperly Positioned or Technically
Imperfect Radiographs
When a fracture is present, the best chance
of seeing it on radiographs is with multiple
views that are properly positioned and tech-
nically adequate. With digital radiography,

492 AJR:203, September 2014

 Pitfalls in Radiography of Lower Extremity Trauma

insufficient tube current (milliamperes) will
result in an underexposed radiograph that
will have less information than a properly ex-
posed radiograph. However, because the dis-
play settings may present the image with the
expected gray scale, contrast, and brightness,
the radiograph may appear to be properly ex-
posed. We present an example in which frac-
tures were obvious on a properly positioned
and exposed radiograph but were not appar-
ent on an improperly positioned and underex-
posed follow-up radiograph obtained several
days later (Fig. 2). Other pitfalls with modern
radiography that may impede the diagnosis of
fractures include the use of image compres-
sion and the use of substandard or handheld
displays. Although radiologists using a PACS
should not encounter these issues, for clini-
cians without U.S. Food and Drug Adminis-
tration–approved display monitors, subtle and
even not-so-subtle abnormalities may be over-
American Journal of Roentgenology 2014.203:492-500.
TABLE 1:  Standard Trauma Radiographs Performed at the
University of Washington
Body Part Standard Views
Hip Anteroposterior and crosstable or frogleg lateral of affected hip
Femur Anteroposterior and lateral
Knee Anteroposterior, lateral, and both obliques
Tibia and fibula Anteroposterior and lateral
Ankle Anteroposterior, oblique (ankle mortise), and lateral
Foot Anteroposterior, oblique, and lateral
Calcaneus Lateral, Harris-Beath (axial)
typically performed. Although the American angulation of the pelvis is often performed
College of Radiology [12] recommends MRI to offset this conundrum [12]. Rotated, and
(rating 9) in favor of CT (rating 6) or radio- therefore foreshortened, views of the proxi-
nuclide bone scan (rating 4) for middle-aged mal femurs should be considered equivocal
or elderly patients whose radiographs show or indeterminate if no actual fracture is seen.
negative or indeterminate findings, there is At the knee, avulsion fractures may occur at
mixed opinion in the literature regarding the the various surfaces of the femur, tibia, fibula,
diagnostic superiority of CT versus MRI to and patella, where soft-tissue structures attach;

looked if displays do not have the appropri-

ate luminance, contrast, bit depth, and image
enhancement tools. For clinicians working in
brightly lit spaces, glare and reflections may
further reduce the information available from
a radiograph [11].
Pitfall 3: Nondisplaced Fractures
Even with properly positioned and techni-
cally excellent radiographs, some fractures
are undetectable on radiographs because
they are nondisplaced. These fractures are
symptomatic and have the appropriate clin-
ical findings and mechanism of injury, but
they are not evident on radiographs. In es-
sence, the radiograph findings are falsely
negative, because the method itself is insuf-
ficient to reveal the fracture. The detection
of acute fractures on radiographs generally
requires that they be displaced to some de-
gree. With a high clinical index of suspicion,
further evaluation with additional imaging
is typically required, particularly if the re-
sults of this imaging will affect clinical man-
agement. An example of this is the older or
elderly adult with hip pain after a ground-
level fall, coupled with an inability to bear
weight. Osteoporosis often further adds to
the difficulty of detecting nondisplaced frac-
tures. Radiograph findings may be negative
or equivocal because diffuse loss of bone
mineral makes nondisplaced fracture lines
less conspicuous. Because the management
of a proximal femur fracture is usually sur-
gical, when the pretest probability of frac-
ture is high according to the clinical presen-
tation, further evaluation with CT or MRI is
exclude the presence of a radiographically
occult hip fracture [13]. CT may provide the
best option if MRI is unavailable or the pa-
tient has a contraindication to MRI. Howev-
er, MRI is superior at detecting bone mar-
row edema (Fig. 3). Bone scans have been
applied to the initial diagnosis of radiograph-
ically occult fractures [14] but have minimal
use in our practice because of the ubiquitous
availability of CT. Bedside sonography has
recently been studied as a modality for de-
tecting fifth metatarsal fractures, essentially
as an extension of the physical examination,
and shows some promise when compared
with radiographs [15]. However, sonography
performed less well than radiography in a
polytrauma screening situation [16].
Pitfall 4: Common Locations of Errors
Prior analyses have stratified common
locations for missed fractures [1, 3, 17]. A
study of overlooked fractures in the emergen-
cy department found that 51.4% of missed
fractures involved the ankle or foot [18]. In
a study by Wei et al. [3], missed fractures of
the lower extremity involved, in descending
order, the foot, the knee, the hip, and the an-
kle. In our experience, site-specific anatom-
ic issues may be troublesome. For example,
an anteroposterior view of the pelvis is taken
with the leg in approximately 15° of internal
rotation in an effort to obtain the most opti-
mal view of the proximal femur. However,
because nonresponsive patients with high-
energy trauma often present with the femur
in external rotation, a Judet view with 40° of
these are often obscured by overlying bones.
Tibial plateau fractures, when nondepressed,
may be difficult to see unless the x-ray beam
happens to be directed along the plane of the
fracture. The presence of a lipohemarthrosis
would indicate the presence of an intraarticular
fracture and, if no fracture is seen, should trig-
ger consideration for CT or MRI.
At the ankle, one must be alert to the pos-
sibility of proximal fibular fractures, beyond
the FOV (Fig. 4), and of foot fractures. For
example, Maisonneuve fracture is a prona-
tion-external rotation injury with concom-
itant distal tibiofibular syndesmotic dis-
ruption and proximal fibular fracture [19].
Understanding the fracture pattern with the
associated pattern of injury mechanism is
crucial, especially in the ankle [20]. The
foot itself has some of the most complex
bony anatomy in the body, with multiple
oddly shaped bones that overlap with one an-
other. The subtle nature of some foot frac-
tures and the complex anatomy may result in
an increased propensity to missed fractures
of the foot. Small osteochondral fractures
of the talar dome or small avulsion frac-
tures around the hindfoot and midfoot may
be difficult to find [21]. The anatomy of the
hindfoot and midfoot makes it challenging
to identify fractures, particularly of the ta-
lus [22] (Fig. 5), cuboid (Fig. 6), cuneiforms
[23–25], anterior process of the calcaneus
[26], and Lisfranc joint [27]. Lisfranc and
Chopart joint injuries can be subtle or occult
on non-weight-bearing radiographs. Delayed
diagnosis of fractures can lead to nonunion,

AJR:203, September 2014 493


secondary osteoarthritis, avascular necrosis,
pseudoarthrosis, and even neuropathic joints
[5, 6, 28]. Calcaneal fractures may be asso-
ciated with lumbar spine fractures. The radi-
ologist should be aware of locations in which
fractures are commonly missed and pay spe-
cial attention to these regions. We typically
use CT or MRI for problem-solving in re-
gions of complex anatomy.
Pitfall 5: Little Avulsion Fractures, Big Trauma
Small avulsion fractures may be easy to
overlook. Sometimes they portend major
injuries. For example, posterior malleolar
avulsion fractures of the ankle usually occur
when the distal fibula is laterally displaced
away from the tibia by forceful abnormal
movement of the talus, rupturing the syndes-
mosis and the anterior tibiofibular ligament
[17] (Fig. 7A). The strong posterior tibiofib-
ular ligament remains intact but avulses off
American Journal of Roentgenology 2014.203:492-500.
the posterior tibia where it attaches. If the
fracture is reduced before radiographs are
obtained, the injury may be overlooked [21].
Another classic example would be the
Segond fracture (Figs. 7B and 7C). This
fracture occurs along the lateral tibia and ap-
pears to be the result of avulsion of the lat-
eral knee joint capsule. There have been nu-
merous studies showing a high association of
the Segond fracture with major soft-tissue in-
jury, including the anterior cruciate ligament
and the menisci [29, 30]. Other frequent
sites of avulsion fractures include the medi-
al and lateral femoral condyles, the median
eminence of the tibia, the fibular head, the
medial and lateral malleoli of the ankle, the
anterolateral margin of the distal tibia, the
dorsal neck of the talus, the anterior process
of the calcaneus, and the bases of the second
and fifth metatarsals. When a small avulsed
fracture fragment is present, the radiologist
should consider the underlying soft-tissue
ramifications by determining which soft-tis-
sue structure attaches to the bone fragment.
Pitfall 6: Bipartite Sesamoid Versus Fracture
Sesamoid bones and accessory ossicles
pose a unique challenge for the radiolo-
gist. Sesamoid bones are often multipartite;
therefore, distinguishing fracture from nor-
mal anatomic variations can be difficult (Fig.
8). The radiologist must rely on the clinical
picture and knowledge of the more predict-
able appearance of the normal multipartite
sesamoid bone. Special attention should be
paid to possible sesamoid injury (stress reac-
tion or fracture) in runners with forefoot pain
494 AJR:203, September 2014
Ha et al.
[31]. Accessory ossicles can be confusing
without a thorough understanding of where
they typically occur. The ankle is a prover-
bial hot spot for accessory bones, as are the
metatarsal phalangeal joints. Although these
ossicles should not be confused with dis-
placed fracture, these small bones should not
be taken for granted, because they too can be
fractured [32, 33].
Pitfall 7: Satisfaction of Search
When radiologists interpret radiographs
with multiple abnormalities and find some
but not all of the abnormalities, satisfaction
of search may be invoked as the cause. Satis-
faction of search occurs when the detection of
one abnormality somehow interferes with the
recognition of others; in other words, abnor-
malities are missed because other abnormali-
ties are found. This phenomenon was initially
studied in chest radiographs in which simulat-
ed lung nodules were added to an experimen-
tal set of cases as distractors but were omit-
ted in the control set [34]. Berbaum et al. [34]
found that radiologists performed more poor-
ly with respect to finding the nonsimulated
abnormalities in the experimental set than in
the control set, confirming a substantial satis-
faction-of-search effect.
In various ways, this finding has been rep-
licated in extremity radiographs. In a series
of experiments, Bernbaum et al. [35, 36] cre-
ated multiimage musculoskeletal cases in
which they were able to test whether an ab-
normality detected in the first image inter-
fered with detection of abnormalities on the
subsequent images with ROC analysis; they
found that the initial finding of nondisplaced
fractures evoked satisfaction-of-search er-
rors but that the initial finding of a severe
fracture with high morbidity did not. Ash-
man et al. [37] simply studied radiologists’
performance on skeletal radiographs with
two or more abnormalities and considered
that a satisfaction-of-search error had oc-
curred whenever there was a failure to find
all of the abnormalities (Fig. 9). Fleck et al.
[38] found that satisfaction of search is af-
fected by the relative frequency of types of
abnormalities, time pressure, and expecta-
tions about the frequency of abnormalities.
Their work suggests that, when observers
look for a particular abnormality and find it,
they become less likely to find a perceptually
different abnormality that is less common. In
their study of gaze dwell times, Berbaum et
al. [39] suggested that satisfaction-of-search
effects were not the result of faulty visual
scanning of the remaining images after the
first abnormality was found. Whether Rog-
ers’ [40] suggested strategy of paying better
attention can systematically reduce satisfac-
tion-of-search errors is unknown, but in our
opinions, it is well worth trying.
Pitfall 8: Faulty Reasoning
Once fractures have been identified, the
radiologist should characterize them so that
further management can be planned. How-
ever, there may be more information that the
radiologist can provide beyond the scope of a
simple fracture description. Fractures of par-
ticular anatomic sites are often more frequent
at particular ages and typically occur as a re-
sult of a specific mechanism. Identification
of a fracture that is atypical for site, age, and
mechanism should lead to further investiga-
tion. For example, fractures of the proximal
femoral shaft (subtrochanteric or intertro-
chanteric-subtrochanteric) typically occur in
healthy adults as a result of a major traumatic
event, such as a motor vehicle crash or a fall
from a height. Proximal femoral shaft frac-
tures may occur as a result of a ground-level
fall in very elderly populations with skeletal
fragility or in those with some underlying con-
dition that predisposes the bone to fracture.
Therefore, the finding of a proximal femoral
shaft fracture in a young or middle-aged adult
as a result of a ground-level fall should trig-
ger immediate suspicion of an underlying pre-
disposing condition. There are often clues to
the underlying pathophysiology on the initial
trauma radiographs. Thickening of the lateral
femoral cortex, especially if there is a triangu-
lar peaked appearance, has been recognized
as characteristic for a bisphosphonate-associ-
ated insufficiency fracture [41] (Fig. 10). The
presence of bone destruction, either permeat-
ed or geographic, may indicate the presence
of a tumor or of osteomyelitis. The proximal
femur is the most common site of bone me-
tastasis [42]. In particular, the presence of a
lesser trochanteric femur fracture in an adult
should elicit strong clinical concern for path-
ologic fracture due to metastatic disease [43,
44]. This information is valuable to the clini-
cian in tailoring treatment.
Pitfall 9: Fractures After Hardware Placement
Fracture evaluation can be challenging in
patients after hardware placement, such as that
seen with fracture fixation or joint replacement,
for various reasons [45, 46]. Dense overlapping
metallic densities can limit visualization of
hardware fractures or periprosthetic bone frac-
 Pitfalls in Radiography of Lower Extremity Trauma
tures. Oblique views are often helpful. Cross-
sectional imaging, such as CT or MRI, can be
limited by metal artifacts and should be per-
formed with modified metal artifact reduction
protocols when available. Hardware implants
alter the stresses on the host bone, resulting in
chronic bone loss where stress-shielding oc-
curs and bony hypertrophy where stresses are
concentrated. When subjected to trauma, forc-
es tend to concentrate where there is an abrupt
interface between implant and bone. Fractures
often begin at those interfaces and then propa-
gate away from the point of concentration. For
example, femoral fractures in patients with hip
implants usually pass through the tip of the
femoral stem (Fig. 11). Fractures through bones
with internal fixation tend to pass through the
cortex at the end of the plate.
Conclusion
Most fractures that are missed on radio-
graphs are the result of errors in perception.
American Journal of Roentgenology 2014.203:492-500.
Many of these misses occur in predictable lo-
cations where the radiographic anatomy is
complex. Specific attention to these anatom-
ic sites may increase fracture detection. Dou-
ble reading of radiographs may avoid some of
these errors but may not be practical or cost ef-
fective [47]. The precise correlation of physical
examination findings—site of maximal pain
and tenderness—with radiographs may be
helpful, even if it requires that the radiologist
examine the patient. With PACS and teleradi-
ology, the radiologist may be at some distance
from the patient, and communication with the
provider who has examined the patient may be
the best that the radiologist can do.
Further imaging may be necessary when the
results are likely to change management. Al-
though splinting and obtaining follow-up ra-
diographs are sensible options for the upper
extremity, because the lower extremities are
weight-bearing, the associated morbidity for a
patient with an undiagnosed fracture or dislo-
cation is often greater. CT is an excellent im-
mediate option; however, MRI often provides
a more comprehensive evaluation for soft-tis-
sue injuries and may allow the identification of
a nondisplaced radiographically and CT-occult
fracture. Some researchers have reported that
sonography may have a role in fracture diag-
nosis as well, but perhaps more for screening at
the point of care [48] rather than problem solv-
ing for radiographically occult fractures.
References
1. Weisel BB, Saunders, RA, Weisel SW. Chapter
23: physical impairment ratings for fractures. In:
AJR:203, September 2014 495
Browner BD, Jupiter JB, Levine AM, Trafton PG,
Krettek C, eds. Skeletal trauma: basic science,
management, and reconstruction, 4th ed. Phila-
delphia, PA: Elsevier, 2009
2. Whang JS, Baker SR, Patel R, Luk L, Castro A
3rd. The causes of medical malpractice suits
against radiologists in the United States. Radiolo-
gy 2013; 266:548–554
3. Wei CJ, Tsai WC, Tiu CM, Wu HT, Chiou HJ,
Chang CY. Systematic analysis of missed extrem-
ity fractures in emergency radiology. Acta Radiol
2006; 47:710–717
4. Leeper WR, Leeper TJ, Vogt KN, Charyk-Stewart
T, Gray DK, Parry NG. The role of trauma team
leaders in missed injuries: does specialty matter? J
Trauma Acute Care Surg 2013; 75:387–390
5. van Rijn J, Dorleijn DM, Boetes B, Wiersma-Tu-
instra S, Moonen S. Missing the Lisfranc fracture:
a case report and review of the literature. J Foot
Ankle Surg 2012; 51:270–274
6. van Dorp KB, de Vries MR, van der Elst M,
Schepers T. Chopart joint injury: a study of outcome
and morbidity. J Foot Ankle Surg 2010; 49:541–545
7. Dorsay TA, Major NM, Helms CA. Cost-effective-
ness of immediate MR imaging versus traditional
follow-up for revealing radiographically occult
scaphoid fractures. AJR 2001; 177:1257–1263
8. Brooks S, Cicuttini FM, Lim S, Taylor D, Stuckey
SL, Wluka AE. Cost effectiveness of adding mag-
netic resonance imaging to the usual management
of suspected scaphoid fractures. Br J Sports Med
2005; 39:75–79
9. Blackmore CC, Mann FA, Wilson AJ., Helical CT
in the primary trauma evaluation of the cervical
spine: an evidence-based approach. Skeletal Ra-
diol 2000; 29:632–639
10. Theocharopoulos N, Chatzakis G, Damilakis J. Is
radiography justified for the evaluation of patients
presenting with cervical spine trauma? Med Phys
2009; 36:4461–4470
11. Krupinski EA, Williams MB, Andriole K, et al;
ACR; AAPM; Society for Imaging Informatics in
Medicine. Digital radiography image quality: im-
age processing and display. J Am Coll Radiol
2007; 4:389–400
12. American College of Radiology. ACR appropri-
ateness criteria: acute hip pain—suspected frac-
ture. American College of Radiology website.
www.acr.org/~/media/ACR/Documents/AppCri-
teria/Diagnostic/AcuteHipPainSuspectedFracture.
pdf. Published 2013. Accessed May 15, 2014
13.
Gill SK, Smith J, Fox R, Chesser TJ. Inves-
tigation of occult hip fractures: the use of CT and
MRI. ScientificWorldJournal 2013; 2013:830319
14. Lewis SL, Rees JI, Thomas GV, Williams LA.
Pitfalls of bone scintigraphy in suspected hip frac-
tures. Br J Radiol 1991; 64:403–408
15.
Yesilaras M, Aksay E, Atilla OD, Sever
M, Kalenderer O. The accuracy of bedside ultraso-
nography as a diagnostic tool for the fifth metatar-
sal fractures. Am J Emerg Med 2014; 32:171–174
16. Bolandparvaz S, Moharamzadeh P, Jamali K, et
al. Comparing diagnostic accuracy of bedside ul-
trasound and radiography for bone fracture
screening in multiple trauma patients at the ED.
Am J Emerg Med 2013; 31:1583–1585
17. Jibri Z, Mukherjee K, Kamath S, Mansour R. Fre-
quently missed findings in acute ankle injury. Se-
min Musculoskelet Radiol 2013; 17:416–428
18. Er E, Kara PH, Oyar O, Ünlüer EE. Overlooked
extremity fractures in the emergency department.
Ulus Travma Acil Cerrahi Derg 2013; 19:25–28
19. Levy BA, Vogt KJ, Herrera DA, Cole PA. Mai-
sonneuve fracture equivalent with proximal tibio-
fibular dislocation: a case report and literature re-
view. J Bone Joint Surg Am 2006; 88:1111–1116
20. Okanobo H, Khurana B, Sheehan S, Duran-Men-
dicuti A, Arianjam A, Ledbetter S. Simplified diag-
nostic algorithm for Lauge-Hansen classification of
ankle injuries. RadioGraphics 2012; 32:E71–E84
21. Prokuski LJ, Saltzman CL. Challenging fractures
of the foot and ankle. Radiol Clin North Am 1997;
35:655–670
22. Dale JD, Ha AS, Chew FS. Update on talar frac-
ture patterns: a large level I trauma center study.
AJR 2013; 201:1087–1092
23.
Eraslan A, Ozyurek S, Erol B, Ercan E. Iso-
lated medial cuneiform fracture: a commonly missed
fracture. BMJ Case Rep 2013; 2013:bcr2013010093
24. Olson RC, Mendicino SS, Rockett MS. Isolated
medial cuneiform fracture: review of the litera-
ture and report of two cases. Foot Ankle Int 2000;
21:150–153
25.
Kou JX, Fortin PT. Commonly missed
peritalar injuries. J Am Acad Orthop Surg 2009;
17:775–786
26. Renfrew DL, el-Khoury GY. Anterior process
fractures of the calcaneus. Skeletal Radiol 1985;
14:121–125
27. Gupta RT, Wadhwa RP, Learch TJ, Herwick SM.
Lisfranc injury: imaging findings for this impor-
tant but often-missed diagnosis. Curr Probl Di-
agn Radiol 2008; 37:115–126
28. Sherief TI, Mucci B, Greiss M. Lisfranc injury:
how frequently does it get missed? And how can
we improve? Injury 2007; 38:856–860
29. Hess T, Rupp S, Hopf T, Gleitz M, Liebler J. Lat-
eral tibial avulsion fractures and disruptions to the
anterior cruciate ligament: a clinical study of their
incidence and correlation. Clin Orthop Relat Res
1994; 303:193–197
30. Gottsegen CJ, Eyer BA, White EA, Learch TJ,
Forrester D. Avulsion fractures of the knee: imag-
ing findings and clinical significance. Radio-
Graphics 2008; 28:1755–1770
31. Kindred J, Truby C, Simons SM. Foot injuries in

runners. Curr Sports Med Rep 2011; 10:249–254
32. Smith JT, Johnson AH, Heckman JD. Non-
operative treatment of an os peroneum fracture in
a high-level athlete: a case report. Clin Orthop
Relat Res 2011; 469:1498–1501
33. Tang JY, Mulcahy H, Chew FS. High energy frac-
ture of the fabella. Radiol Case Rep 2010; 5:454
34. Berbaum KS, Franken EA Jr, Dorfman DD, et al.
Satisfaction of search in diagnostic radiology. In-
vest Radiol 1990; 25:133–140
35. Berbaum KS. Satisfaction of search in osteoradi-
ology. AJR 2001; 177:252–253
36. Berbaum KS, El-Khoury GY, Ohashi K, et al. Sat-
isfaction of search in multitrauma patients: sever-
ity of detected fractures. Acad Radiol 2007;
14:711–722
37. Ashman CJ, Yu JS, Wolfman D. Satisfaction of
search in osteoradiology. AJR 2000; 175:541–544
38. Fleck MS, Samei E, Mitroff SR. Generalized
“satisfaction of search”: adverse influences on
dual-target search accuracy. J Exp Psychol Appl
American Journal of Roentgenology 2014.203:492-500.
Fig. 1—20-year-old man who sustained transient lateral patellar dislocation that
spontaneously reduced on field of injury. Fractures were not visible on lateral and
anteroposterior radiographs. Sunrise view shows multiple avulsion fragments
(arrow) along medial margin of patella.
Fig. 2—19-year-old man after sports injury.
A, Initial oblique radiograph shows incomplete
second and third metatarsal shaft fractures.
Reprinted with permission from [49].
B, Follow-up radiograph obtained 1 week later at
outpatient office without radiologic technologists
does not show metatarsal fractures because of
underpenetration and improper tube angulation. Note
lack of trabecular bone detail and poor visualization
of tarsometatarsal and naviculocuneiform joints.
496 AJR:203, September 2014
Ha et al.
2010; 16:60–71
39. Berbaum KS, Brandser EA, Franken EA, Dorfman
DD, Caldwell RT, Krupinski EA. Gaze dwell times
on acute trauma injuries missed because of satisfac-
tion of search. Acad Radiol 2001; 8:304–314
40. Rogers LF. Keep looking: satisfaction of search.
AJR 2000; 175:287
41. Porrino JA Jr, Kohl CA, Taljanovic M, Rogers LF.
Diagnosis of proximal femoral insufficiency frac-
tures in patients receiving bisphosphonate thera-
py. AJR 2010; 194:1061–1064
42. Jacofsky DJ, Haidukewych GJ. Management of
pathologic fractures of the proximal femur: state
of the art. J Orthop Trauma 2004; 18:459–469
43. Rouvillain JL, Jawahdou R, Labrada Blanco O,
Benchikh-El-Fegoun A, Enkaoua E, Uzel M. Iso-
lated lesser trochanter fracture in adults: an early
indicator of tumor infiltration. Orthop Traumatol
Surg Res 2011; 97:217–220
44. Phillips CD, Pope TL Jr, Jones JE, Keats TE,
MacMillan RH 3rd. Nontraumatic avulsion of the
A B
lesser trochanter: a pathognomonic sign of meta-
static disease? Skeletal Radiol 1988; 17:106–110
45.
Schwarzkopf R, Oni JK, Marwin SE. To-
tal hip arthroplasty periprosthetic femoral frac-
tures: a review of classification and current treat-
ment. Bull Hosp Jt Dis 2013; 71:68–78
46. Haidukewych GJ, Langford J, Liporace FA. Revi-
sion for periprosthetic fractures of the hip and
knee. J Bone Joint Surg Am 2013; 95:368–376
47. Kung JW, Melenevsky Y, Hochman MG, et al.
On-call musculoskeletal radiographs: discrepan-
cy rates between radiology residents and muscu-
loskeletal radiologists. AJR 2013; 200:856–859
48. Safran O, Goldman V, Applbaum Y, et al. Post-
traumatic painful hip: sonography as a screening
test for occult hip fractures. J Ultrasound Med
2009; 28:1447–1452
49.
Mulcahy H, Chew FS. Foot (case 9–27):
location 1636. In: Chew FS, Maldjian C, eds. Bro-
ken bones: the x-ray atlas of fractures. Seattle,
WA: BareBonesBooks, 2009
 Pitfalls in Radiography of Lower Extremity Trauma

A B C
Fig. 3—65-year-old man after ground-level fall with nondisplaced fracture not seen on radiographs.
A, Anteroposterior radiograph appears normal. Lateral view was also normal. Patient complained of right hip pain and was unable to bear weight or walk.
B, Coronal T1-weighted MRI shows nondisplaced femoral neck fracture.
C, Fracture was internally fixed with three compression screws.
American Journal of Roentgenology 2014.203:492-500.

Fig. 4—28-year-old woman after ground-level fall.

A, Oblique view of ankle shows syndesmotic
widening and subtle medial malleolar avulsion
fracture.
B, Lateral view of proximal leg shows oblique
proximal fibular shaft fracture, constituting
Maisonneuve fracture.
A B

AJR:203, September 2014 497

 Ha et al.

Fig. 5—53-year-old man with talus fracture.

A and B, Anteroposterior (A) and lateral (B) radiographs
show comminuted medial talar body fracture.
C and D, Subsequent sagittal (C) and axial (D) CT
images more comprehensively show additional
oblique fracture (arrows) through talar body
extending into subtalar joint.

A B
American Journal of Roentgenology 2014.203:492-500.

C D

Fig. 6—35-year-old woman with foot pain after fall.

A, On radiographs, including lateral view, fracture is
difficult to see even in retrospect.
B, Intraarticular fracture of cuboid at fourth
tarsometatarsal joint (arrow) is seen on this sagittal
CT reformation.
A B

498 AJR:203, September 2014

 Pitfalls in Radiography of Lower Extremity Trauma

A B C
Fig. 7—Two patients with avulsion fracture signaling underlying injury.
A, 32-year-old man with ankle injury sustained in fall. Lateral radiograph shows minimally displaced posterior malleolar fracture (arrow), indicative of rupture of ankle
syndesmosis.
B and C, 30-year-old man after car-versus-pedestrian crash. Coronal (B) and sagittal (C) STIR MR images show acute Segond fracture at lateral tibial plateau (arrow, B)
and full-thickness anterior cruciate ligament tear.
American Journal of Roentgenology 2014.203:492-500.

Fig. 8—32-year-old woman who experienced foot
injury while playing soccer. Anteroposterior radiograph
shows bipartite medial sesamoid with separation
extending diagonally across bone. At proximal aspect,
there is transverse avulsion fracture (arrow), and
sesamoid has retracted distally. Medial soft tissues are
swollen. Diagnosis of turf toe was made.
A B
Fig. 9—61-year-old woman who sustained polytrauma in motor vehicle crash. Multiple fractures and
dislocations led to satisfaction of search.
A and B, Initial evaluation of anteroposterior oblique (A) and lateral (B) radiographs of foot focused on multiple
metatarsal and toe fractures and multiple metatarsophalangeal joint dislocations. Calcaneal fractures were
initially overlooked.

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 Ha et al.

Fig. 10—Two patients with unusual fractures.

A, 65-year-old woman who presented to emergency
department after ground-level fall at shopping mall.
Anteroposterior radiograph shows comminuted
subtrochanteric femur fracture. She had been taking
alendronic acid (Fosamax, Merck) for 10 years for
osteoporosis. Abnormal thickening of proximal
lateral femoral cortex (arrow) is partially obscured by
trauma board.
B, 46-year-old man after ground-level fall.
Anteroposterior radiograph shows subtrochanteric-
intertrochanteric proximal femur fracture with
separate lesser trochanter fragment and marked
angulation. Pathology at time of intramedullary rod
placement showed metastatic cancer.
American Journal of Roentgenology 2014.203:492-500.

A B

Fig. 11—54-year-old man with left total hip

arthroplasty.
A and B, Frontal radiograph of pelvis (A) and frog-
lateral view of left hip (B) show oblique fracture
(arrow, B) of mid shaft of femur extending to level of
femoral stem tip.
A B

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