Older Patients, Wiser Care

Don't Trust X-Rays More Than Your Own Eyes

Last updated: May 03, 2010

Doctor shaking hands with a recovered elderly man

A new study in the American Journal of Roentgenology confirms something I tell the families of my patients all the time: Your eyes are one of the most important medical tools your loved one has. What you see -- and then communicate to medical staff -- can make all the difference.

The new study, conducted at Duke University, showed that many hip and pelvis fractures that are visible on MRI aren't picked up by X-rays.

That's exactly what happened to one of my patients last year. Mr. C was initially [misdiagnosed] (https://www.caring.com/blogs/older-patients-wiser-care/misdiagnosed-fractured-pelvis) in the emergency room after a fall when an X-ray there missed his subtle (yet very painful) pelvic fracture. And because of his dementia, Mr. C didn't say he was in pain, which might have led the ER docs to take a closer look.

How could this happen? This study didn't speculate, but one thing I know happens is that doctors usually pay attention when younger and middle-aged adults describe problems walking, or other serious physical limitations, following an accident. In other words, they have reason to look beyond the initial X-ray (often with an MRI). But it's trickier with the frail elderly; after all, we've all seen plenty of older people who are unable to walk at all, much less around the block.

Of course, plenty of older people are able to walk around the block. And when a person like that suddenly can't, or is suddenly too tired to do so, that's a change in their functioning.

Changes in function often signal an injury, or perhaps another health condition that's getting out of whack. (Another common example is [delirium] (https://www.caring.com/blogs/older-patients-wiser-care/5-reasons-a-very-common-hospital-problem-is-often-overlooked), a change in mental function.) Geriatricians also care about function because preserving an older person's ability to walk and do things for himself is often closely linked to quality of life, and to reducing a caregiver's burden.

Some losses in function can't be reversed, but many can, especially if the injury or illness is treated quickly. So we geriatricians are obsessed with function. That's why I'll often ask things like, "Was this patient able to walk before he came to the hospital? And how far?"

And who knows about what's "normal" and what's newly different in an older patient better than his or her caregiver? Family caregivers are usually the first to notice an important change in a loved one.

My prescription: Watch closely, speak loudly!

So after a fall, don't rely on the doctors alone to tell you if there's a fracture or other important injury present. Don't rely on the X-rays. Go by what you see. And if you notice a change in what the person in your care is able to do, or not do, compared to the recent past, speak up loud and clear. Emphasize how your loved one is different from the way he or she was, and over what period of time you've noticed the change.

That Mr. C I mentioned earlier? He couldn't walk after his fall a year ago, but his caregivers had mentioned how this was new and different for this 85-year-old. An MRI had therefore been ordered, and it confirmed the pelvic fracture the X-ray had missed. We arranged for him to get extra pain medicine and physical therapy. I just saw him last week for a follow-up. I'm happy to say that he not only got back on his feet, he's still walking.