Easily missed fractures

See Fracture Immobilisation & Casting for general splinting/casting technique, review timing and referral thresholds — this page covers fracture-specific recognition and pitfalls.

Scaphoid fracture

Most often an axial loading injury to the thumb (FOOSH), but can follow a direct blow. Fractures are frequently undisplaced and invisible on initial X-ray — if clinically tender in the anatomical snuffbox or on axial thumb loading, treat as a scaphoid fracture regardless of X-ray: short arb backslab - Thumb spica no longer needed.

• Proximal-pole fractures carry high avascular necrosis risk — proximal 1/3 ≈ 33% AVN risk; proximal 1/5 (the pole itself) ≈ 100%.
• Management (immobilisation vs surgical fixation) is guided by stability, per orthopaedics; hand physiotherapy helps post-injury.

Radial head fracture

1–4% of upper limb fractures; FOOSH with axial load through the radial head. Easily missed without adequate views.

• Fat pad (“sail”) sign indicates a minimally displaced, otherwise occult fracture — the posterior fat pad is always abnormal if visible; the anterior fat pad is only abnormal if enlarged.
• Treatment is usually non-operative unless significantly comminuted or dislocated; long-arm backslab (above-elbow, bent) if immobilising.

Calcaneal and subtalar fractures

Axial load — falling onto straightened legs from height, or direct foot impact.

• Böhler’s angle (lateral view): line from the highest point of the anterior process to the highest point of the posterior facet, and a line tangential to the superior tuberosity edge. Normal 20–40°; a decreased angle indicates posterior-facet collapse.
• Angle of Gissane: line along the lateral margin of the posterior facet and a line anterior to the beak of the calcaneus. Normal 120–145°; an increased angle likewise reflects posterior-facet collapse.
• CT is the gold-standard imaging.

Lisfranc injury

A tarsometatarsal fracture-dislocation — traumatic disruption between the medial cuneiform and the base of the 2nd metatarsal. Mechanism: MVAs, falls from height, athletic injury via indirect rotational force + axial load through a hyperplantarflexed forefoot. Get a weight-bearing X-ray — missed injuries progress to chronic foot deformity and dysfunction, so maintain a high index of suspicion (see also foot fractures).

Five critical radiographic signs of midfoot instability (diagnostic on AP/oblique/lateral views): discontinuity of the line from the medial base of the 2nd MT to the medial middle cuneiform; widening of the 1st–2nd intermetatarsal interval ± a “fleck sign” avulsion fragment; dorsal displacement of the proximal 1st/2nd MT base; medial base of the 4th MT not aligning with the medial cuboid; disruption of the medial column line.

Supracondylar fracture (paediatric)

The most common paediatric traumatic fracture, age 5–7, equal sex incidence. 95–98% extension type, 5% flexion type; mechanism FOOSH (extension) or a fall on the olecranon (flexion). Often accompanied by an ipsilateral radius fracture. Minimally displaced fractures may show only a fat-pad sign on X-ray — immobilise in a backslab and refer (urgency depends on type).

Associated neuropraxia (nearly all resolve spontaneously after reduction/fixation):

• Anterior interosseous nerve (most common) — can’t make the “OK” sign
• Radial nerve (2nd most common) — sensory loss over the volar index finger
• Ulnar nerve (flexion-type injuries) — can’t extend wrist MCP or thumb IP joints

Vascular compromise occurs in 5–17% but is often mitigated by rich collateral circulation.

Gartland type	Features	Management
I	Non-displaced. Beware subtle medial comminution → cubitus varus (technically not type I — needs reduction/pinning)	Cast immobilisation 3–4 weeks, X-ray at 1 week
II	Displaced, posterior cortex/periosteal hinge intact, sagittal-plane deformity only	Typically closed reduction + percutaneous pinning (CRPP)
III	Displaced, often 2–3 planes	CRPP, or open reduction if needed
IV	Complete periosteal disruption, unstable in flexion and extension (diagnosed under anaesthesia)	CRPP, or open reduction if needed
Medial comminution	Collapse of the medial column, loss of Baumann angle → varus malunion (“gunstock” deformity)	CRPP, often needs significant valgus force to reduce
Flexion type	Fall on the olecranon	CRPP, more likely to need open reduction

Seymour fracture

A displaced Salter-Harris II fracture of a distal phalanx at the physis, from an axial stubbing injury forcing the digit into hyperflexion — in the lower limb this is usually the great toe. Easily missed because the fracture line and any germinal-matrix laceration are hidden under the nail; the only clue may be a small subungual/proximal nail-fold haematoma, pain, and (if the toe) a limp. Multi-view X-ray shows a Salter-Harris II fracture with flexion deformity at the fracture site.

This is functionally an open fracture — the nail bed/germinal matrix is typically interposed in the fracture gap, seeding it with skin flora — so it needs prompt irrigation, debridement of the interposed tissue, fracture reduction and antibiotics, not just a splint or buddy-strap. Refer rather than manage as a routine toe injury.

Related pages

• Basic fracture management (general principles) — see lower limb fractures, knee fractures & dislocations, shoulder injuries, forearm / elbow injuries, wrist / hand injuries, ankle fractures & dislocations, foot fractures
• Head, spine & chest fractures
• Stress fractures
• Approach to the Limping Child (Seymour fracture and plantar puncture wounds in the context of a paediatric limp)
• Fingertip & Nail Bed Injuries (finger Seymour fracture management, subungual haematoma, nail bed laceration)