John Thomas sign – a memorable but misleading sign in hip fractures

Murphy, Ian; Murphy, C.G.; Heffernan, Eric J.

doi:10.1016/j.otsr.2013.12.017

Cited by 5 publications

(9 citation statements)

References 10 publications

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“…They retrospectively reviewed AP pelvis radiographs of 200 males, of which 100 had a hip fracture and 100 were controls. Their results showed only an accuracy of 46%, and their conclusions determined that this sign is no better than the toss of a coin in relation to hip fractures [11]. These findings are similar to a study conducted by Ya'ish and Baloch who retrospectively reviewed pelvic radiographs of 100 males with hip fractures and compared them with 100 males without hip fractures, and noted the direction of penile shadowing with a sensitivity of only 30% [13].…”

Section: Discussionsupporting

confidence: 64%

“…Unfortunately, there is little substantial evidence within the literature regarding the use of pelvic shadowing as a reliable soft tissue change to predict laterality of hip pathology or injury. Several studies have failed to demonstrate a correlation between pelvic shadowing and hip fracture laterality, with one study describing this sign as "less accurate than the toss of a coin" [11][12][13][14][15]. Murphy et al attempted to find a relationship between pelvic shadowing and not only with hip fracture side but also penile size and angulation.…”

Section: Discussionmentioning

confidence: 99%

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Pelvic Shadowing as a Diagnostic Predictor of Orthopedic Pathology in Orthopedic Trauma Patients

Skura¹,

EBAUGH²,

Passias³

et al. 2021

Cureus

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IntroductionThe Throckmorton sign, or John Thomas sign, is a well-established orthopedic eponym, anecdotally used in orthopedic surgery to correlate the direction of male genitalia, observed on a pelvic radiograph, with the laterality of an associated orthopedic pathology. In earlier studies, the direction of pelvic shadowing on Xray has been neither a credible nor a reliable predictor of fracture laterality. Given this small body of evidence, we sought to further investigate the relationship between peri-trochanteric hip fracture laterality and male genitalia lie. MethodA single-center retrospective chart review was conducted of 397 consecutive male patients who received pelvic radiographs performed upon entry to an urban level 1 trauma center. Exclusion criteria included age less than 18 years or a prior history of pelvic or urological surgery. Of this cohort, 360 patients met the inclusion criteria and underwent investigation. ResultsThe study population had an average age of 42 years (range: 18-91 years). Statistical analysis yielded a 4.24 relative risk with pelvic shadowing laterality and respective peri-trochanteric hip fracture sidedness. Additionally, there was a 4.63 and 9.88 relative risk of tibial shaft fractures and distal radius fractures having a concomitant positive Throckmorton Sign, respectively. ConclusionPelvic shadowing can be used as an additional diagnostic tool in predicting peri-trochanteric hip fracture sidedness in a trauma bay setting.

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Section: Discussionsupporting

confidence: 64%

Section: Discussionmentioning

confidence: 99%

Pelvic Shadowing as a Diagnostic Predictor of Orthopedic Pathology in Orthopedic Trauma Patients

Skura¹,

EBAUGH²,

Passias³

et al. 2021

Cureus

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show abstract

“…It is believed that a penile shadow would point to the side of fracture in a pelvis, and this is considered a positive John Thomas Sign (Murphy, Murphy, & Heffernan, 2014;Thomas, Lyons, & Walker, 1998). However, it is inconclusive in this case report because there are bilateral fractures in the pelvis, and the penis pointed to the left side.…”

Section: Discussionmentioning

confidence: 99%

Penile shadow artefact overlapping fractures

Chan¹

2014

RadOpen

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Soft tissue shadows are commonly seen on pelvic radiographs, and radiographers may overlook or are unaware that these shadows could be artefacts. In a case study, shadow of a penis superimposed with the fracture lines at pubic ramus and it was questioned whether a fracture of ramus ischio-pubis is present. Further radiographic views were performed to demonstrate the fractures without any artefact. There are other possible pelvic artefacts that may be seen and neglected on pelvic radiographs, thus it may lead to misdiagnosis of pelvic fracture. This essay should be served as a reminder for radiographers to recognize artefacts and differentiate it from pathology.

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“…Sensitivities and specificities were extracted from the relevant studies, 4 ,5,8-14 where available. These values were used to calculate the Log Odds Ratio and associated 95% confidence model for each study.…”

Section: Data Synthesis and Statistical Analysismentioning

confidence: 99%

“…This sign is defined as positive, when the penile shadow points towards the side of a hip or pelvic fracture in male patients. 4 Few studies have objectively described the diagnostic value of the JTS. There is, however, a need to explore the literature regarding this sign as some studies have suggested a 'higher than chance' correlation between the JTS and a unilateral hip fracture.…”

Section: Introductionmentioning

confidence: 99%

The ‘John Thomas’ sign and pelvic fractures—Fact or humorous myth?: A systematic review and meta-analysis

Gerber

Laher

Enyuma

et al. 2019

Journal of Clinical Orthopaedics and Trauma

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An incidental and sometimes humorous finding on an Antero-Posterior (AP) pelvis X-ray view is that of the John Thomas Sign (JTS), which is defined as positive, when the penile shadow points towards the side of a hip or pelvic fracture in male patients. Despite previous research reports and studies performed on the JTS sign, uncertainty with regards to its clinical relevance still remains. The objective of this review was to assess the clinical validity and accuracy of this sign by performing a systematic review and meta-analysis. Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was performed (May 2017), using the following databases: BMJ best practice, Cochrane Database of Systematic Reviews, EMBASE, PubMed and Scopus. Studies comparing the predictability of the JTS were critically appraised. The summary effect (and 95% CI) was estimated using a random effect model and the Restricted Maximum Likelihood Method. The pooled sensitivity as well as the summary effect log odds ratio was determined. Selected studies were further ranked for quality and relevance using the Critical Appraisal Skills Program (CASP) (Oxford 2013) tool. Results: In total, nine articles were isolated and assessed. A total of 1942 participants were included. The mean sample size amongst these included studies was 243 participants with a median of 198 participants. Since the necessary data needed for the Meta-analysis was only present in the 6/9 studies assessed, these 6 were analyzed further. The JTS was positive in 1089 out of 1439 patients with a pooled sensitivity of 75.7% (95%CI, 73.4%-77.9%). There was a large variation in the sensitivity and specificity amongst studies, accounting for a non-significant summary Odds Ratio effect of -0.03. Conclusions: Based on this review, there is insufficient statistical evidence to support the reliability of the JTS to predict the laterality in the case of a hip fracture on the standard AP pelvis x-ray.

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John Thomas sign – a memorable but misleading sign in hip fractures

Abstract: Level III Case control study.

Cited by 5 publications

References 10 publications

Pelvic Shadowing as a Diagnostic Predictor of Orthopedic Pathology in Orthopedic Trauma Patients

Pelvic Shadowing as a Diagnostic Predictor of Orthopedic Pathology in Orthopedic Trauma Patients

Penile shadow artefact overlapping fractures

The ‘John Thomas’ sign and pelvic fractures—Fact or humorous myth?: A systematic review and meta-analysis

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