Perhaps, in some cultures plain radiography has virtually been abolished.
However I don't believe this is practicable, or indeed logical, in our
system of health care. I think the plain skull radiograph is an excellent
investigation in the conscious head injured patient. Where such patients
have local signs suggestive of a fracture, then a plain film will readily
determine if they have a fracture or not - much more accurately than a CT
will. The plain film then acts as a clear risk stratifier; those with a
fracture are at considerably increased risk of further complications, and
many would now suggest they must therefore be scanned (although I agree with
Tim's views on the merits of observation). If the patient has no fracture,
he is then at a very low risk of further complications and, all other things
being equal, can be managed as an outpatient. The plain skull radiograph
remains a quick and effective risk stratifier in the conscious head injured
patient. It is readily available and easily interpreted (although SHOs
struggle with the nuances of this). It is less valuable in the comatose
patient, although can still be helpful in the management of the drunk
patient (concussion and intoxication can be distinguished with experience!).
The plain radiograph is immensely helpful in gun shot wound to the head, and
finally the plain radiograph will establish the extent of fracture
depression much more accurately than a CT will, as the plain film will
display the entire fracture fragment, while the CT will only demonstrate
cross sections.
I don't follow the logic of your last sentence, yes the pick up is very low,
but that is part of the reason for continuing to do skull x-rays, as to CT
all these patients would require a huge number of CTs in otherwise well
patients. Besides CT will miss many skull fractures, depending on the
orientation of the fracture and the slices of the scan, and the bony detail
on CT is nowhere near as intricate and detailed as that seen on plain films.
In other words an early "normal" CT may miss a fracture, and the patient
might later run into complications.
Adrian Fogarty
----- Original Message -----
From: "Rowley Cottingham" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, September 26, 2001 8:32 PM
Subject: Head injuries.
> I believe that we should abandon plain film radiography in the management
of head injury.
> My view is that we should CT scan or nothing, as the pick up rate on plain
film is
> ludicrously low, and if you do see a fracture you are obliged to scan
anyway. Comments?
>
> Best wishes,
>
> Rowley Cottingham
>
> [log in to unmask]
> http://www.emergencyunit.com
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