When I arrived at the Canadian emergency department, they took a series of X-rays that picked up the breaks in thumb and shoulder but showed nothing in my pelvis or hip. Their explanation for my pain and inability to walk: strained tendons and ligaments. The prescription: Get some exercise, walk around.
But walking wasn’t helping, and after I got home a U.S. orthopedist ordered an MRI scan to see what might have been missed. That’s when I learned that I had three breaks in my pelvis and a hairline fracture of the left femur, or thighbone.
To scan or not to scan
In a U.S. emergency department, staff would probably have done head-to-toe CT scans, experts have told me, to identify any bone breaks that didn’t show up on the X-rays. (My earlier story noted a study that found that Americans were almost twice as likely to get CT scans as Canadians when visiting the ED.)
The MRI gave me an explanation for my continuing, disabling pelvic pain. But getting it earlier might not have made a difference in treatment or in the healing process, says Andrew Pollak, chief of the Division of Orthopaedic Traumatology at the University of Maryland School of Medicine.
With minimally displaced pelvic fractures — meaning the broken bone ends are very slightly separated — such as mine, many doctors would suggest exactly what the Canadian ED staff recommended for what they thought were soft tissue injuries: rest and exercise. Other orthopedists would recommend surgery. There’s no data that show which approach is right long-term, says Pollak.
The hip specialist I saw didn’t recommend surgery, and I decided to leave well enough alone.
As I began to follow up on my other injuries I learned a lot about medicine’s increasing specialization: No single orthopedist would treat my myriad injuries, and I eventually acquired three specialists.
I also learned that lack of clarity about treatment was the rule rather than the exception. Take my thumb. The break had knocked it out of alignment by 50 degrees. In Canada, the specialist told me surgery wasn’t necessary.
But ED care, no matter where you get it, is intended to assess your injuries and stabilize you. It’s not necessarily the final word on treatment. Back in the States, the rule of thumb, literally, is that a misalignment of 35 degrees or more should be fixed, says Douglas Hanel, a professor of orthopedic surgery at the University of Washington who specializes in hand and microvascular surgery. But that’s based on the collective wisdom of orthopedists, not on data, says Hanel.
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