The Journal for Nurse Practitioners 16 (2020) 15e18

Contents lists available at ScienceDirect

The Journal for Nurse Practitioners

journal homepage: www.npjournal.org

Imaging Considerations in Musculoskeletal Trauma

Rachel Merton, MSN, AGPCNP

a b s t r a c t
Keywords: Musculoskeletal trauma is among the most common reasons for people to seek medical attention. Appro-
falls priate imaging is a key component to the initial assessment and ongoing evaluation of all trauma patients.
orthopedics
The indications for specific radiographic views and advanced imaging vary depending on the injury. This
radiology
trauma
article reviews recommended imaging for common orthopedic injuries and trauma injuries requiring special
attention because of their association with morbidity and mortality. Nurse practitioners in acute and primary
care settings should be familiar with the indicated imaging for these injuries to ensure timely and complete
diagnosis while not causing harm to the patient.
© 2019 Elsevier Inc. All rights reserved.

Trauma is a frequent cause of musculoskeletal injury and 1 of
the most common reasons for patients to present to emergency
departments or to a health care provider’s office.1 In the United
States, trauma accounts for over 150,000 deaths and over 3 million
nonfatal injuries per year.2 Motor vehicleerelated injuries send
more than 2.3 million people to hospital emergency departments
every year, and falls are the leading cause of fatal and nonfatal in-
juries in people over 65 years of age.3,4
Nurse practitioners in acute and primary care settings should be
familiar with the indicated imaging for common orthopedic in-
juries to ensure timely and complete diagnosis while not incurring
unnecessary cost or radiation exposure to the patient. Ordering
appropriate imaging can decrease the time to intervention, identify
associated injuries, and aid in surgical planning.5-7 This article re-
views imaging recommendations and considerations for common
musculoskeletal injuries caused by severe and nonelife-threatening
traumas.
Pelvic Imaging in Severe Trauma Patients
Pateints who have experienced severe trauma pose a unique
challenge to providers, and imaging plays a crucial role in evaluating
and caring for them. The physical examination’s reliability may be
limited by the patient’s altered level of consciousness, presence of
intubation, or other distracting or life-threatening injuries.6,8 Often,
multiple body systems are affected, and orthopedic injuries are not
always the highest priority. Additionally, obvious clinical signs of
fractures or dislocations, such as swelling, bruising, or obvious
deformity, may be absent.8 As a result, the patient should be evalu-
ated according to advanced trauma life support guidelines; this
evaluation includes a primary survey, which assesses for life-
threatening conditions, and a secondary survey, which is a
complete head-to-toe examination to evaluate any injuries not
addressed in the primary survey.9
Pelvic X-rays (PXRs) are a standard component of the primary
survey because pelvic fractures can be a source of life-threatening
bleeding.8,9 PXRs can be obtained more quickly than computed
tomographic (CT) scans, thus allowing the orthopedic surgeon to
quickly reduce a hip fracture or dislocation in an otherwise stable
patient.5,8
The use of PXRs in hemodynamically stable trauma patients
undergoing pelvic CT scanning has previously been called into
question because CT scans are more sensitive at detecting pelvic
fractures than PXRs.5,8 However, more recent studies have shown
PXRs are still an important aspect of the primary survey because
they decrease time to reduction of a fracture or dislocation and
limit unnecessary radiation exposure and cost.5,8 Orthopedic sur-
geons require detailed postreduction imaging for surgical planning
and to assess for new injury caused by the reduction itself.5,8
Therefore, patients whose pelvic pathology is first noted on CT
imaging must undergo a second, postreduction CT scan, adding to
the patients’ radiation exposure and cost that would have been
avoided had a PXR been obtained on arrival.5,8
Calcaneal Fractures
Although calcaneal fractures account for only 1% to 4% of all
fractures, the calcaneus is the most frequently fractured tarsal
bone.7,10,11 More importantly, over 75% of patients with a calcaneus
fracture will have additional injury; therefore, it is essential that
these patients are subjected to a thorough assessment, including a
physical examination and imaging.7 More than 90% of calcaneus
fractures result from motor vehicle crashes (MVCs) or falls from
heights.7,10 The high energy of these traumas can easily cause other

https://doi.org/10.1016/j.nurpra.2019.06.019
1555-4155/© 2019 Elsevier Inc. All rights reserved.
16 R. Merton / The Journal for Nurse Practitioners 16 (2020) 15e18
injuries and make for a challenging physical examination because
the patient may not be conscious or reliable during the
examination.
Initial imaging should include anteroposterior (AP), lateral, and
oblique radiographs of the foot and ankle.10 When assessing for
possible fracture, providers should order radiographs of the
affected body part as well as the joints above and below the injury
to rule out additional injury or intra-articular involvement.12 This is
especially true with calcaneus fractures because, as noted earlier,
they are highly associated with additional injuries. A review of
patients with calcaneus fractures in the National Trauma Data Bank
for 2011 to 2012 found that 61% had associated lower extremity
fractures, most commonly in the foot and ankle.7 A CT scan of the
calcaneus fractures should be ordered for further classification of
the injury and to aid in operative planning.10,13 Magnetic resonance
imaging (MRI) is not indicated to diagnose calcaneal fractures in the
patient who has experienced high energy trauma, although it may
be helpful in diagnosing calcaneal stress fractures in the outpatient
setting.10
High-energy calcaneal fractures are also associated with verte-
bral injuries. Bohl et al7 found that 23% of patients with calcaneal
fractures had concurrent spine fractures, usually in the lumbar
spine. Thus, radiographs of the lumbar spine are recommended in
all patients with acute calcaneal fractures.7
Spine Evaluation in Trauma Patients
All trauma patients should be assumed to have a cervical spine
(C-spine) injury until proven otherwise.14 C-spine fractures occur in
only 2% to 6% of trauma patients, but these must be thoroughly
evaluated or ruled out because of their association with high
morbidity and mortality.15 Thoracolumbar spinal fractures are
more common, accounting for 50% to 60% of all spinal injuries.16
Most spine fractures are associated with high-energy trauma or
falls in the elderly.14,17
At minimum, imaging should include AP and lateral radiographs
of the entire spine, as well as an odontoid (or open mouth) view of
the C-spine.14,17 In the patient with acute trauma, it is acceptable to
use CT imaging first, especially in unconscious or intermediate- to
high-risk patients.14,17 To assess for associated vascular injury,
computed tomographic angiography of the head and neck should
be ordered on any patient found to have a fracture of C1-C2 or a
cervical vertebral body or transverse foramen fracture, subluxation,
or ligamentous injury at any level (there are additional non-
orthopedic indications for head and neck computed tomographic
angiography not discussed in this article).18
CT imaging has become the first-line spine imaging of choice in
patients with trauma because it is faster and less expensive than
MRI.17 However, MRI is superior for detecting spinal cord injuries,
ligamentous injuries, epidural hemorrhages, and traumatic disc
herniation.17 MRI of the spine is appropriate for evaluating trauma
patients with neurologic deficits and for surgical planning.16,17
However, MRI is not indicated in patients without neurologic def-
icits because it can increase the length of hospital stay and signif-
icantly increases the cost of evaluation without changing the
clinical management of the patient.16 Additionally MRI is not
practical in patients during the acute trauma period. They would
need to be thoroughly checked for metallic foreign bodies before
undergoing MRI; need close monitoring, which is difficult in an MR
scanner; and may require magnetic resonanceecompatible moni-
toring and support devices.17
Gunshot Wounds
Ballistic injuries require special attention because they can
cause fractures that do not follow typical patterns.19 Even
low-energy gunshot wounds (GSWs) (ie, those caused by weapons
[usually hand guns] with a muzzle velocity of < 350 m [2,000 ft] per
second) can cause larger fractures than expected because a great
amount of kinetic energy is transmitted from the projectile to the
bone.19,20 Plain radiographs are usually adequate for extra-articular
fracture evaluation. However, Hwang et al19 found that intra-
articular fracture extension from a GSW cannot be ruled out after
negative plain x-rays. According to their study, intra-articular
extension from GSW-related fractures to the diaphysis (the shaft)
of the distal femur was missed 44% of the time when evaluated
with plain radiographs alone. They had similar results when eval-
uating fractures to the metaphysis (the area between the shaft and
the epiphysis) of the femur and tibia. Given the low sensitivity of
plain radiographs for evaluating intra-articular fractures caused by
GSWs, Hwang et al recommend obtaining CT scans for all diaphy-
seal fractures of the distal femur and all metaphyseal fractures of
the femur and tibia caused by GSWs.
Advanced Imaging for Suspected Hip Fractures
Falls are a common cause of trauma, and they cause the vast
majority of isolated hip fractures.21 Most hip fractures occur in
people over the age of 65, and the number of hip fractures is ex-
pected to rise as the population ages.21,22 Plain radiography, using
AP and lateral views, is the most common diagnostic tool for hip
fractures, but 2% to 10% of hip fractures cannot be seen on plain
films, and, for these injuries, advanced imaging is warranted.22,23
The American Academy of Orthopaedic Surgeons clinical prac-
tice guidelines recommend MRI as the advanced imaging of choice
in patients over 65 with a suspected hip fracture not detected on
plain radiographs.24 The guidelines cite MRI’s ability to detect hip
fractures, especially in the elderly, and to identify other causes of
hip pain when no fracture is present.24 The guidelines were pub-
lished in 2014, and at the time, there was limited research on the
use of CT scans for identifying occult hip fractures. CT scans carry
the added risk of radiation exposure; therefore, the use of bone
scans was to be considered in cases in which MRI was not
available.24
Since the publication of the American Academy of Orthopaedic
Surgeons guidelines, researchers have directly compared MRI and
CT imaging for diagnosing occult hip fractures and confirmed MRI
as the superior method for detecting intertrochanteric fractures
and fissures.22,23 However, MRI and CT imaging were found to be
equally effective in diagnosing femoral neck fractures, and a CT scan
is a reasonable imaging option when MRI is not available or con-
traindicated.22,23 MRIs are more costly and more difficult for junior
radiology residents to interpret than CT scans.22 The American
College of Radiology (ACR) acknowledges the increased radiation
exposure of CT imaging but states that both MRI and CT scans are
usually appropriate to evaluate for occult hip fracture.25 The ACR
does not recommend the use of a bone scan for this injury.25
Ankle Injuries
Acute and primary care providers should be familiar with ankle
imaging indications. A survey of British general practices found that
ankles were the second-most commonly fractured area of the lower
limb (behind hip/femur fractures), and, in the United States, ankles
were the second-most commonly injured lower extremity part
causing people to present to emergency departments.26,27
 R. Merton / The Journal for Nurse Practitioners 16 (2020) 15e18
The Ottawa Ankle and Midfoot Rules constitute a well-
established criteria for determining whether the patient should
undergo foot or ankle radiography.28,29 The rules state patients
with pain in the malleolar or midfoot areas (for the ankle), the base
of the fifth metatarsal, or navicular bones (for the midfoot) as well
as either point tenderness over the same areas or an inability to
weight bear 4 steps immediately after injury and when admitted to
the emergency department.28,29 These rules have proven to be
highly sensitive with low specificity and are used as the first step in
determining whether patients meet the ACR Appropriateness
Criteria for ankle radiography.28,29 In some cases, patients who do
not meet Ottawa criteria should also be considered for radiography.
These cases include patients with neurologic deficits or who have
persistent pain related to ankle trauma and were not imaged at the
time of injury.29 Radiographs should include AP, lateral, and
mortise views.
Advanced imaging is indicated for complex fractures or to
evaluate soft tissue injury. A CT scan is recommended if plain ra-
diographs show a fracture of the talus.29,30 MRI is indicated to
evaluate syndesmotic injuries, also known as high ankle sprains;
this area includes the distal tibia and fibula, distal anterior tibio-
fibular ligament, the distal posterior tibiofibular ligament, the
transverse ligament, and the interosseous ligament.29,31,32 MRI is
also recommended for evaluating osteochondral defects, peroneal
tendon pathology, and ankle pain persisting anywhere from 1 to 8
weeks after initial injury.29,33
Common Upper Extremity Fractures
Distal radius fractures, scaphoid fractures, and proximal hu-
merus fractures are common injuries related to falls. Distal radius
fractures are the most common orthopedic injury, and scaphoids
are the most commonly fractured carpal bone.34,35 Proximal hu-
merus fractures are usually caused by a fall in an elderly patient or
high-energy trauma in a younger patient.36
Most distal radius fractures require only plain radiographs (AP,
lateral, and oblique views) for diagnosis.34,37,38 Radiographs of the
elbow and hand should also be obtained to evaluate for associated
injuries.12 If the fracture is, or may be, intra-articular, a CT scan is
indicated to evaluate the extent of joint involvement and for sur-
gical planning.34 If soft tissue injury is suspected, MRI is indicated
to evaluate for injuries commonly caused by falls onto outstretched
hands.34 These include injuries to the triangular fibrocartilage
complex, scapholunate ligament injuries, and lunotriquetral
injuries.34
Falls are also the usual suspects in scaphoid fractures, which
often occur in contact sports or falls from standing.37 Timely
diagnosis is important because scaphoid fractures are at high risk
for nonunion and osteonecrosis because of their delicate blood
supply.38 Initial radiologic evaluation should include AP, lateral, and
oblique views as well as a scaphoid (or Stecher) view, with the wrist
in 30 degrees of extension and 20 degrees of ulnar deviation.35,37-39
Even when radiographed correctly, up to 30% of acute scaphoid
fractures are missed on plain films.39 Several advanced imaging
techniques may be used if there is clinical suspicion for a scaphoid
fracture with negative radiographs. MRIs are the most sensitive
technique for diagnosing occult scaphoid fractures within 24 hours
of injury.35,39 Bone scans are useful for diagnosing occult scaphoid
fractures later, with a specificity of 98% and sensitivity of 100%
when performed 72 hours after injury.35 CT imaging is useful for
evaluating the exact location of a scaphoid fracture and the extent
of its collapse and fragment dislocation.35,39 Although MRI is the
most sensitive for diagnosing occult scaphoid fractures, CT scans
with 0.5- to 1-mm cuts provide the greatest detail of fracture
morphology, making them the most useful technique for surgical
17
planning.35,39,40 Schmitt and Rosenthal39 suggest obtaining MRI
only if CT findings are inconclusive because of the greater detail
that CT imaging provides.
Proximal humerus fractures are commonly the result of
low-energy falls in elderly patients with osteopenic bone and
high-energy traumas, such as MVCs or falls from heights in younger
patients.36,41 Initial imaging should consist of a shoulder trauma
series of plain radiographs; this includes a true AP (or Grashey)
view, scapular Y, and axillary views.36,41 The axillary view is espe-
cially helpful for evaluating greater and lesser tuberosity fractures,
humeral head-splitting fractures, and glenohumeral dislocations.41
A CT scan is indicated for further evaluation of intra-articular
fractures and for surgical planning.36,41 CT scans are also helpful
for determining the position of the humeral head and greater tu-
berosity when their positions are unclear on plain films and for
diagnosing occult proximal humerus fractures.36,41 MRI may also be
helpful for diagnosing occult fractures but is generally not used for
surgical planning, unless the injury is in fact to the rotator cuff
rather than to the bone itself.36,41
Conclusion
Musculoskeletal trauma is a common occurrence in the United
States and 1 of the most common reasons for people to seek
medical attention.1-4 Appropriate imaging is a key component to
the initial assessment and ongoing evaluation of all patients who
have experienced trauma.9 Being aware of the indicated imaging
for musculoskeletal injuries enables nurse practitioners to ensure
timely and accurate diagnosis, thus expediting specialty treatment,
aiding diagnosis and surgical planning, and reducing unnecessary
cost and radiation exposure to the patient.
References
1. All Injuries. Centers for Disease Control and Prevention, National Center
for Health Statistics. https://www.cdc.gov/nchs/fastats/injury.htm. 2017.
Accessed May 8, 2019.
2. Trauma Facts. The American Association for the Surgery of Trauma. 2019.
http://www.aast.org/trauma-facts. Accessed May 8, 2019.
3. Bergen G, Stevens MR. Falls and fall injuries among adults aged
65 years-
United States, 2014. Morb Mortal Wkly Rep. 2016;65(37):993-998. https://
doi.org/10.1093/geront/gnw074.
4. Centers for Disease Control and Prevention. CDC winnable battles final report,
motor vehicle injuries. https://www.cdc.gov/winnablebattles/report/motor.
html. 2017. Accessed May 8, 2019.
5. Walker MR, El Naga AN, Atassi OH, Perkins CH, Mitchell SA. Effect of initial
emergency room imaging choice on time to hip reduction and repeat imaging.
Injury. 2019;50(3):686-689. https://doi.org/10.1016/j.injury.2019.01.032.
6. Artigas Martín JM, Martí de Gracia M, Claraco Vega LM, Parrilla Herranz P.
Radiology and imaging techniques in severe trauma. Med Intensiva.
2015;39(1):49-59. https://doi.org/10.1016/j.medine.2014.06.003.
7. Bohl DD, Ondeck NT, Samuel AM, et al. Demographics, mechanisms of injury,
and concurrent injuries associated with calcaneus fractures: a study of 14 516
patients in the American College of Surgeons National Trauma Data Bank. Foot
Ankle Spec. 2017;10(5):402-410. https://doi.org/10.1177/1938640016679703.
8. Verbeek DO, Burgess AR. Importance of pelvic radiography for initial trauma
assessment: an orthopedic perspective. J Emerg Med. 2016;50(6):852-858.
https://doi.org/10.1016/j.jemermed.2015.03.048.
9. American College of Surgeons Committee on Trauma. Advanced Trauma Life
Support Student Course Manual. 9th ed. Chicago, IL: American College of Sur-
geons; 2012.
10. Hatch D. Calcaneus fractures. Orthobullets. https://www.orthobullets.com/
trauma/1051/calcaneus-fractures?expandLeftMenu¼true. 2019. Accessed
May 8, 2019.
11. Wei N, Zhou Y, Chang W, Zhang Y, Chen W. Displaced intra-articular calcaneal
fractures: classification and treatment. Orthopedics. 2017;40(6):e921-e929.
https://doi.org/10.3928/01477447-20170907-02.
12. Alboulafia A, Andras L, Dierkman B, et al. General orthopaedics. In: Griffin L, ed.
Essentials of Musculoskeletal Care. 4th ed. Rosemont, IL: American Academy of
Orthopaedic Surgeons; 2010.
13. Huxford M. Foot and Ankle. In: Benavides J, Clanton T, eds. Essentials of
Musculoskeletal Care. Rosemont, IL: American Academy of Orthopaedic Sur-
geons; 2010.
18 R. Merton / The Journal for Nurse Practitioners 16 (2020) 15e18
14. Karadsheh M. Cervical Spine Trauma Evaluation. Orthobullets. https://
www.orthobullets.com/spine/2012/cervical-spine-trauma-evaluation?
expandLeftMenu¼true. 2019. Accessed May 8, 2019.
15. Alessandrino F, Bono CM, Potter CA, Harris MB, Sodickson AD, Khurana B.
Spectrum of diagnostic errors in cervical spine trauma imaging and their
clinical significance. Emerg Radiol. 2019. https://doi.org/10.1007/s10140-019-
01685-0 [Epub ahead of print].
16. Khoury L, Chang E, Hill D, Shams S, Sim V. Management of thoracic and lumbar
spine fractures: is MRI necessary in patients without neurological deficits? Am
Surg. 2019;85(3):306-311.
17. Splendiani A, Bruno F, Patriarca L, et al. Thoracic spine trauma: advanced
imaging modality. Radiol Med. 2016;121(10):780-792. https://doi.org/10.1007/
s11547-016-0657-y.
18. Western Trauma Association. Screening for and treatment of blunt cerebro-
vascular injuries algorithm. Western Trauma Association Algorithms.
https://westerntrauma.org/algorithms/ScreeningForAndTreatmentOfBluntCere
brovascularInjuries/RiskFactorsForBCVI.html. 2012. Accessed April 24, 2019.
19. Hwang JS, Koury KL, Gorgy G, et al. Evaluation of intra-articular fracture
extension after gunshot wounds to the lower extremity: plain radiographs
versus computer tomography. J Orthop Trauma. 2017;31(6):334-338. https://
doi.org/10.1097/BOT.0000000000000786.
20. Weatherford B. Gunshot wounds. Orthobullets. https://www.orthobullets.com/
trauma/1059/gun-shot-wounds?expandLeftMenu¼true. 2018. Accessed April
6, 2019.
21. LeBlanc KE, Muncie HL Jr, LeBlanc LL. Hip fracture: diagnosis, treatment, and
secondary prevention. Am Fam Physician. 2014;89(12):945-951. https://
doi.org/10.1016/S0002-838X(14)60194-5.
22. Haubro M, Stougaard C, Torfing T, Overgaard S. Sensitivity and specificity of
CT- and MRI-scanning in evaluation of occult fracture of the proximal femur.
Injury. 2015;46(8):1557-1561. https://doi.org/10.1016/j.injury.2015.05.006.
23. Pejic A, Hansson S, Rogmark C. Magnetic resonance imaging for verifying hip
fracture diagnosis why, when and how? Injury. 2017;48(3):687-691. https://
doi.org/10.1016/j.injury.2017.01.025.
24. American Academy of Orthopaedic Surgeons. Management of hip fractures in
the elderly: evidence-based clinical practice guideline. http://www.aaos.org/
research/guidelines/HipFxGuideline.pdf. 2014. Accessed April 6, 2019.
25. American College of Radiology. American College of Radiology ACR Appro-
priateness Criteria® acute hip pain-suspected fracture. https://acsearch.acr.
org/docs/3082587/Narrative/. 2018. Accessed May 10, 2019.
26. Kaye JA, Jick H. Epidemiology of lower limb fractures in general practice in the
United Kingdom. Inj Prev. 2004;10(6):368-374. https://doi.org/10.1136/
ip.2004.005843.
27. Lambers K, Ootes D, Ring D. Incidence of patients with lower extremity in-
juries presenting to US emergency departments by anatomic region, disease
category, and age. Clin Orthop Relat Res. 2012;470(1):284-290. https://doi.org/
10.1007/s11999-011-1982-z.
28. Beckenkamp PR, Lin CW, Macaskill P, Michaleff ZA, Maher CG, Moseley AM.
Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic
review with meta-analysis. Br J Sports Med. 2017;51(6):504-510. https://
doi.org/10.1136/bjsports-2016-096858.
29. Mosher T, Kransdorf M, Adler R, et al. Acute Trauma to the Ankle. American
College of Radiology, 2019. https://acsearch.acr.org/docs/69436/Narrative/.
Accessed May 10, 2019.
30. Weatherford B. Talar neck fractures. Orthobullets. https://www.orthobullets.
com/trauma/1048/talar-neck-fractures?expandLeftMenu¼true. 2019.
Accessed April 24, 2019.
31. Karadsheh M. High Ankle Sprain & Syndesmosis Injury. Ortho Bullets. https://
www.orthobullets.com/foot-and-ankle/7029/high-ankle-sprain-and-syndesmosis-
injury?expandLeftMenu¼true. Published 2016, Accessed April 24, 2019.
32. Hermans JJ, Beumer A, De Jong TAW, Kleinrensink GJ. Anatomy of the distal
tibiofibular syndesmosis in adults: a pictorial essay with a multimodality
approach. J Anat. 2010;217(6):633-645. https://doi.org/10.1111/j.1469-
7580.2010.01302.x.
33. Macknet D, Weatherford B. Ankle sprain. Orthobullets. https://www.
orthobullets.com/foot-and-ankle/7028/ankle-sprain?expandLeftMenu¼true.
2019. Accessed May 8, 2019.
34. Ahn L, Vitale M, Franko O. Distal radius fractures. Orthobullets. https://www.
orthobullets.com/trauma/1027/distal-radius-fractures. 2019. Accessed April
24, 2019.
35. Abbasi D. Scaphoid fracture. Orthobullets. https://www.orthobullets.com/
hand/6034/scaphoid-fracture. 2018. Accessed April 24, 2019.
36. Torchia M, Taylor BC. Proximal humerus fractures. OrthbBullets. https://www.
orthobullets.com/trauma/1015/proximal-humerus-fractures. 2019. Accessed
April 24, 2019.
37. Marco CA, Humphries A, Mozeleski E. Common orthopedic injuries. Emerg
Med Rep. www.reliasmedia.com/articles/140086-common-orthopedic-in-
juries. 2017. Accessed April 24, 2019.
38. Huxford M. Hand and Wrist. In: Seiler J, ed. Essentials of Musculoskeletal
Care. 4th ed. Rosemont, IL: American Academy of Orthopaedic Surgeons;
2010.
39. Schmitt R, Rosenthal H. Imaging of scaphoid fractures according to the new S3
guidelines. RoeFo-Fortschritte auf dem Gebiete der Roentgenstrahlen und der
Bildgebenden Verfahren. 2016;188(5):459-469.
40. Arsalan-Werner A, Sauerbier M, Mehling IM. Current concepts for the treat-
ment of acute scaphoid fractures. Eur J Trauma Emerg Surg. 2016;42(1):3-10.
https://doi.org/10.1007/s00068-015-0587-8.
41. Gaetke-udager K, Yablon CM. Fractures around the shoulder: radiologic update
on surgical fixation techniques. Semin Musculoskelet Radiol. 2019;23(2):
99-108.
Rachel Merton, MSN, AGPCNP, ONC is a Trauma Nurse Practitioner at Duke University
Hospital in Durham, NC. She can be reached at rachelfelice@gmail.com.
In compliance with national ethical guidelines, the author reports no relationships
with business or industry that would pose a conflict of interest.