Ive had a few interesting cases and near misses in my career in A&E. Im sure most clinicians would agree that the very young and those with dementia or severe mental health issues are very difficult to assess. Often most of the history-take will come from carers or family and more often than not these injuries are unwitnessed.
I can recall a case whereby an elderly lady with dementia came by ambulance with pain in her legs. She had an unwitnessed fall in the care home where she lived and had been screaming out in pain which was not like her normal behaviour. An examination and assessment was done by a senior doctor and x-rays of the hips and pelvis were ordered.
The x-rays of hip and pelvis were completely normal and she was given pain relief and discharged home via ambulance. When the ambulance came to pick her up to transfer her back to the care home they expressed concerns about how much pain she was in when they tried to move her. I was asked to go and re-examine her as the doctor has finished her shift. I found she appeared to be very tender around both of her femurs but it was hard to be sure as she just screamed out when ever you touched her and was unable to tell you where the pain was due to her advanced dementia. I ordered more x-rays of both of her femurs before and asked the ambulance crew to leave so that we could re-assess her.
The x-rays showed bilateral femur fractures. She was admitted for surgery under Trauma and Orthopaedics. It just goes to show even senior doctors can miss things when patients are confused or unable to speak.
Another case I remember was of a 10 month old child that was starting to walk and becoming much more mobile but she had a fall off the sofa and her Mum was concerned she no longer wanted to walk on her right leg.
On examination there did not appear to be any bony tenderness, there was no bruising, no swelling, she did not flinch when I was moving her foot or ankle but did not appear to want to put her left foot to the floor when standing. I decided to send her for an xray of her ankle and saw that she had indeed fractured her fibula a ‘toddlers fracture’. I had to apply a plaster cast and refer her to the Trauma and Orthopaedics specialists.
Children, especially the very young are extremely difficult to assess as they often dont complain of pain and just get on with things. They dont neccessarily show any external signs of trauma such as bruising or swelling as there bones are so soft. Often they dont complain even where you move the effected joint. I believe you should always have a high suspicion of fracture in children as there bones are weaker than the ligaments until they have reached maturity.
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