Chapter 6: Chapter 0005: Fractures That Can’t Be Seen on A CT Scan (Part 1)

“Ding Dong! Task overcompleted, a third experience pack has been awarded.”

After the interview came the written exam. As someone who once ranked within the top ten of his entire school, the exam was a breeze.

At noon, Sanbo provided a free lunch.

After the meal, Yang Ping took a tour around Sanbo Hospital.

The hospital was indeed impressive. Its main building consisted of two towers––the Surgery Building and the Internal Medicine Building––each over thirty floors high, connected by sky bridges on each level.

There were also, among others, an Administration Building, an Outpatient Building, an Emergency Building, Medical Technology Building, and the Overseas Chinese Building––each one a six- to eight-story structure, reasonably distributed, with a layout that was pleasing to the eye.

The rooftops of the Surgery Building and the Internal Medicine Building served as a helipad, with a helicopter parked on the roof of the Surgery Building. It added an air of grandeur, making it a symbol of the hospital.

Yang Ping also visited the orthopedics department. Sanbo Hospital’s orthopedics division had over a hundred beds, divided into four areas: trauma, spine, joint, and sports medicine. Director Han was the head of the whole orthopedics department, as well as the head of the trauma division.

Orthopedics is a broad specialty. Many big hospitals sub-categorize orthopedics into trauma, spine, joint, sports medicine. Some even split off a pediatric orthopedics section. Some hospitals with a strong hand surgery program have a separate hand surgery department. Some larger regional medical centers also have orthopedic oncology.

The more technologically advanced the hospital, the further down they divided. For example, trauma could be split into upper and lower limb, the spine into cervical, thoracic, and lumbar, and the joints into hip and knee, etc.

In other words, some people specialized in fractures of the upper limb while some specialized in fractures of the lower limb––something unimaginable in an ordinary hospital but a common practice in top-tier hospitals.

There’s a top orthopedic surgeon from a prestigious hospital in Beijing who specializes in upper cervical vertebrae surgery, including the base of the skull, the first and second vertebrae. Such surgeries are rare in regular hospitals, perhaps performed once a year, whereas this surgeon can perform them year-round, treating patients from all over the country.

After spending the entire day touring Sanbo, Yang Ping went to a nearby restaurant for dinner before heading back to his rented room in the city via the subway.

Little Five hadn’t returned for many days, leaving Yang Ping with some peaceful quietude. Excited by the novelty, Yang Ping again entered the system, opened his gift box, and started using his gift—the training program for interpreting radiographic images of limb fractures, which lasted for fourteen days.

Upon entering the training space, a variety of limb fracture images appeared on the electronic viewer, one after another. There were X-ray images, CT scans, MRI scans, and the system’s mechanical female voice would also provide detailed explanations. After fourteen days of rigorous training, Yang Ping had seen over ten thousand images.

A few days later, he received a call notifying him that he had passed the interview and could start working in the orthopedics department. Yang Ping was so thrilled that he almost jumped with joy.

On his first day at work, Yang Ping arrived very early.

‘The clumsy bird flies early.’ Although he didn’t consider himself clumsy, he was sure that starting early wouldn’t be mistaken.

The duty room, men’s changing room, women’s changing room, meeting room, dining room, teaching room, and therapy room––Yang had to familiarize himself with these places as soon as possible to be able to work efficiently.

As everyone trickled in, their shift started promptly at eight o’clock. Everyone lined up in a U-shaped formation; at the open end of the U stood a projector, at the base of the U sat the department head along with several team leaders, on the left sat the male doctors, and on the right sat the female nurses.

The doctors were all dressed uniformly—white shirts, dark trousers, dark shoes, neckties, and white gowns over them.

The nurses, all taller than one point six meters, were dressed in slim-fit blue nurse uniforms. Their hair was tied up and secured with a black hairnet, making them look youthful and charming.

Among the doctors, there was actually a female doctor named Tang Fei. She was dressed in blue jeans and a goose-yellow T-shirt. Her hair was tied up, and her female doctor’s white coat was very neat. Standing amidst male doctors, she was a dazzling bit of color.

After the handover, Director Han briefly introduced the new doctors including Yang Ping, and everyone applauded to welcome the newcomers.

If there were no objections to the handover, the nurses would leave the office and start their busy workday.

The doctors began a brief morning meeting, discussing the surgeries performed on the previous day, and the surgeries to be performed that day. They would put the radiographs on a viewer, and give a brief report.

Each team took turns to report their respective cases.

One of the patients, named He Jianmin, a seventy-six-year-old man, caught Yang Ping’s attention. His X-ray showed a fracture of the left femoral shaft. Surgery to fix it with an interlocking nail was planned to be the first surgery of the day.

In this patient’s X-ray, Yang Ping noticed a femoral neck fracture which was not mentioned in the handover diagnosis.

Based on the choice of surgical procedure, it was apparent that the operating surgeon was completely oblivious of the femoral neck fracture.

Such fractures are concealed and almost impossible to detect on X-rays and CT scans.

Yang Ping had undergone training to interpret over ten thousand images of limb fractures, which enabled him to detect even concealed fractures with great precision.

If there indeed was a concealed femoral neck fracture, the surgeon would fall into a pitfall. Being unaware of the femoral neck fracture, he would proceed with the usual surgical procedure, creating an entry point in the upper femur, then twisting or hammering the nail into the marrow cavity of the femur. Such actions could potentially turn the concealed neck fracture into a visible fracture without the surgeon even realizing it.

Upon post-operative re-examination of X-ray: Damn it! The neck of the femur is fractured!

What to do then? Surely, you can’t just ignore the fractured femoral neck?

They would then need to explain to the patient: “Sorry, you have an untreated femoral neck fracture and need a second surgery to address it.”

The patient’s reaction: “Why did the previous x-ray not show a fracture but now it’s visible? Did the surgery you performed cause the fracture? And now you’re trying to trick me into a second operation?” At this point, the disputes arise.

“Ding dong, Novice Task Three: Help your coworkers avoid diagnostic pitfalls and present the final novice gift box.”

So it’s a chain of four gifts, how generous of the system.

After the x-ray film was reviewed, Director Han scanned the room, speaking succinctly, “Does anyone have any questions? If not, the meeting is over.”

This patient definitely has a femoral neck fracture, it cannot be mistaken. I’ve seen tens of thousands of these x-rays and developed a keen eye for detail. I won’t misstep.

I must remind the chief surgeon to avoid this unnecessary dispute.

Immediately, Yang Ping raised his hand, and all doctors focused their attention on him.

Director Han asked, “Xiao Yang, what do you want to say?”

Some people have already gone to the door, ready to leave, but then they retreated.

Questioning someone else’s diagnosis and treatment plan is a risky move, especially on the first day of work, and under the public eye.

If I don’t say something, will I just watch others fall into a trap?

After pondering, Yang Ping said, “Could you please pull out the x-rays of He Jianmin for review?”

The X-ray and CT scans were brought up and projected onto the screen.

“Is there a problem?” Director Han asked.

Yang Ping humbly replied: “I’m sorry for wasting everyone’s time. I suspect that this patient has a concealed fracture of the femoral neck. We have had similar cases in our hospital in the past and suffered losses, so I’m particularly sensitive about such cases.”

Anyway, a few words won’t waste too much time. Since there are doubts, just say it out. Director Han says: “Xiao Yang, go ahead.”

With the approval of the director, Yang Ping continued, “I had a case where the preoperative X-ray and CT scan did not reveal a femoral neck fracture, but the postoperative X-ray showed a hip fracture. We were forced to suggest a second surgery to fix the femur neck to the patient, and the patient didn’t understand why the preoperative films did not show a fracture, but the postoperative review did. They insisted it was the surgeon’s mistake and they caused the fracture, causing disputes and even litigation. I thought about it and concluded that this case was a result of dashboard injury…

“Hmm, then you can discuss this case, where do you suspect?” Director Han encouraged Yang Ping.

Yang Ping continued: “When I just looked at the x-ray, I noticed swelling in the soft tissues in front of the knee, which indicates a bruise and is similar to a dashboard injury, which immediately reminded me of a hidden femoral neck fracture. On careful examination, the trabeculae of the femoral neck on the x-ray are slightly disordered, and there’s a fold on the cortex on one of the CT slices, which made me even more suspicious. I’m sure it’s nothing to laugh about, but now, whenever I see a femoral fracture, all I can think of is a hidden femoral neck fracture, and it makes me break out into a cold sweat.”

After all that was said, some people were amused by the last sentence.

The group responsible for this patient is led by Tian Yuan, Director Tian, vice chief physician, doctoral graduate from Huaxi Medical University.

When he looked at Yang Ping and stood up to sit at the computer connected to the projector, he flipped through the X-rays and CT scans repeatedly on the computer.

Indeed, there was a slight disorder of trabeculae in the femoral neck on the X-ray and one cortical fold on the CT scan. But it’s subtle, almost imperceptible. Without a foregone conclusion, you wouldn’t notice it at all.

“The CT scan is the gold standard for diagnosing fractures, isn’t it better than an MRI at detecting fractures? If a CT scan doesn’t show a fracture, can an MRI detect it?” The resident doctor, Zhang Lin, asked, sounding a bit aggravated.

“Exactly!” Fang Yan, the attending doctor under Tian Yuan, agreed.

Director Han reprimanded, “He’s not wrong, the MRI is the best diagnostic tool for detecting hidden fractures of the femoral neck. X-rays and CT scans may not show it. Xiao Zhang, you need to brush up on your knowledge.”

Zhang Lin was publicly criticized and seemed a bit upset.

After browsing the films, Tian Yuan turned his head and said to Director Han, “Director, Xiao Yang really reminded me. Indeed, there are doubts.”

The patient had already begun anesthesia in the operating room.

Tian Yuan immediately picked up his phone: “Xiaobo, can you please check the patient’s left knee for any swelling or bruising?”

“Since there are doubts, let’s pause the operation and clarify the situation?” Director Han made the final decision.

The other doctors, including several department directors, all needed to stretch their necks to carefully review the films on the projection screen. Where can you see the fracture?

Their eyes hurt from looking so hard, and they still couldn’t see it!