A fall on an outstretched hand suggests scaphoid fracture. The mechanism of trauma may also be helpful to locate the potential fracture. In wrist trauma, for instance, the interpreter should pay close attention to the scaphoid and triquetrum, which are the two most commonly injured carpal bones. Moreover, one should be aware of the commonly encountered lesions and their locations. The general rule is to perform two orthogonal views, but more specific views should be added if there is any suspicion of fracture. Trabecular angulation, impaction lines, and sclerotic bands also suggest fracture in osseous structures with a significant proportion of cancellous bone such as proximal femur. Osseous lines should be checked for integrity (e.g., acetabular rim in the hip). However, the radiographic technique (positioning in particular) must be optimal for this evaluation to be valid. Fat pads should be carefully examined for convexity, which implies joint effusion (e.g., in the hip and elbow joints). Awareness of normal anatomic features is crucial for the interpreter to be able to detect subtle signs of fracture. Correct diagnosis primarily relies on the reader’s experience. The detection of subtle signs of fracture requires a high standard for the acquisition technique and a thorough and systematic interpretation of radiographic images. Radiography is the first step for detection of fractures. This can only be achieved by ensuring high quality of examination with the available imaging tools. Nonetheless, not every department can afford all new technologies, and radiologists sometimes have to face the challenge of providing the highest diagnostic performance with basic imaging tools. Thanks to rapid technological advancement, new and more efficient imaging hardware is constantly released for all imaging modalities including CT, MRI, nuclear medicine, and ultrasound. Our aim is to raise the awareness of both clinicians and radiologists to this common problem by illustrating various cases of radiographically occult and subtle fractures. Pediatric and microtrabecular fractures-known as bone bruises and contusions-are outside the scope of this paper. The term “stress fracture” is more general and encompasses both of the latter two entities. Occult and subtle fractures may be divided into: (1) fractures associated with high energy trauma (2) fatigue fracture secondary to repetitive and unusual stress being applied to bone with normal elastic resistance and (3) insufficiency fracture resulting from normal or minimal stress on a bone with decreased elastic resistance. It will also prevent inherent complications such as nonunion, malunion, premature osteoarthritis, and avascular osteonecrosis (as in scaphoid fracture). Early detection, on the other hand, enables more effective treatment, a shorter hospitalization period if necessary, and decreased medical costs in the long run. The burden entailed in missing these fractures includes prolonged pain with a loss of function, and disability. In both cases, a negative radiographic diagnosis with prominent clinical suspicion of osseous injury will prompt advanced imaging examination such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, and nuclear medicine to confirm or exclude the clinically suspected diagnosis. While occult fractures present no radiographic findings, radiographically subtle fractures are easily overlooked on initial radiographs. Failure to recognize the subtle signs of osseous injury is one of the reasons behind this major diagnostic challenge. Indeed, fractures represent up to 80% of the missed diagnoses in the emergency department. Radiographically occult and subtle fractures are a common diagnostic challenge in daily practice. Our aim is to raise the awareness of radiologists and clinicians in these cases by presenting illustrative cases and a discussion of the relevant literature. Advanced imaging tools such as computed tomography, magnetic resonance imaging, and scintigraphy are highly valuable in this context. Early detection of these fractures is crucial to explain the patient’s symptoms and prevent further complications. Independently of the cause, the initial radiographic examination can be negative either because the findings seem normal or are too subtle. They may be divided into (1) “high energy trauma fracture,” (2) “fatigue fracture” from cyclical and sustained mechanical stress, and (3) “insufficiency fracture” occurring in weakened bone (e.g., in osteoporosis and postradiotherapy). Radiographically occult and subtle fractures are a diagnostic challenge.
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