The Case:
A 15-year-old presented with right index finger pain. He states he was catching a football and it hit the tip of his right index finger and forcibly flexed it causing pain at his DIP joint. He was initially seen in triage and right hand radiographs were obtained and read by the radiology resident as negative (Figure 1). On examination, the patient had tenderness over the dorsal aspect of the DIP joint with weak extension. Based on the exam and suspicion of a fracture seen on the hand radiographs, the patient was sent back to get dedicated radiographs of the involved digit (Figure 2). Soon after, the radiologist called to report an intra-articular Mallet fracture. The patient’s DIP joint was splinted in extension and sent for orthopedic follow-up.
Why it matters:
This case highlights the importance of the clinical exam and ordering the best possible radiograph for the clinical situation. Hand radiographs were ordered by a triage nurse, in this case, in an effort to speed up the length of stay. While good practice, the hand radiographs were not the best radiographs to obtain in an isolated finger injury. Overlap of bone and more distractions take the radiologist’s attention away from the critical area; and allow for potential error. Unfortunately, the electronic medical record, as currently set up, makes it easy to order a hand radiograph, but not straightforward to order a radiograph of a digit. Hand radiographs are included in a common radiology folder. A search of “digit” will not pull up finger radiographs. A search of “finger” is needed; and then the clinician must search through multiple listings of items to find the right order. Correcting the EMR and educating clinicians and staff on the best radiograph to obtain may help in the future avoid a potential medical error.
Authored by Scott Sherman, MD