Systematic analysis of missed extremity fractures in emergency radiology

Purpose: To systematically analyze fractures in the extremities that were missed in the initial radiological report, primarily on plain radiographs, in the emergency department (ED). Material and Methods: From January 2003 to June 2004, 2407 new patients were confirmed to have fractures in the extremities in the ED. A total of 3081 fractures were confirmed. In the initial radiological reports, 115 fractures in 108 patients were missed. One musculoskeletal radiologist and one emergency radiologist independently carried out a second review of these images. The easily missed fracture sites were recorded. The possible reasons for misinterpretation were determined by consensus. Results: The most frequent location for missed fractures, expressed as a percentage of all fractures in the same location, was the foot (7.6%), followed by the knee (6.3%), elbow (6.0%), hand (5.4%), wrist (4.1%), hip (3.9%), ankle (2.8%), and shoulder (1.9%). The average percentage for all missed fractures was 3.7%. On the second review, 70% of the initially missed fractures were identified. Analysis of the possible reasons for missed fractures showed the most common reason was subtlety of the fracture. Conclusion: The overall percentage of missed fractures in the extremities was 3.7%. Only 33% of the initially missed fractures were attributed to radiographically imperceptible lesions. Adequate training for physicians and radiologists in the ED may reduce the rate of missed fractures.